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Permit#: - l9 1 b t) • 20 tl
PRINCIPLE STRUCTURE PERMIT
APPLICATION
Permit Fee:$ c1 '�
Town of Queensbury PDo tq,Cb' .4 Q
742 Bay Road,Queensbury,NY 12804 *Rec Fee:$
P:518-761-8256 www.queensbury.net Invoice#: V5rD O
Project Location: I Ilv C ►t Ls
Tax Map ID #: .0 9 . 12 - l "310 Subdivision Name: 1\17- bC1E C>_tC->
*TOWN BD.RESOLUTION 86-2013: $850 recreation fee for new dwelling units: single family,duplexes/two-family,
multiple family, apartments, condominiums,townhouses, and/or manufactured & modular homes, but not mobile
homes. This Is In addition to the permit fee(s).
CONTACT INFORMATION:
• Applicant:
Name(s): -LC�td S � c ems L LC
Mailing Address, C/S/Z: 1 MAIza0t4S WAY, NI #p�l��tI lid, h1Y
Cell Phone: ( 5t ) '8`=%cl • to31 i Land Line: ( 5►e, ) tc, t I
Email: --1 vNt4,---R co).--it
• Primary Owner(s):
Name(s):
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: ( ( ( �/] r T1
Email:
• Contractor(s):
fil APR022019
Business Name: TOWN OF QUEENSBURY
Contact Name(s): L3UILDING&COL3ES
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: ( )
Email:
• Architect(s)JEngineer(s):
Business Name: V-Et 'ice- " zr ►�° e••
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: ( 4319. 240Z Land Line: (
Email: Y—fu "c\z-a cx.>I e tZ z
Contact Person for Building & Code Compliance: t-c' c-A®
Cell Phone: ( ) 4351.314-4 Land Line: ( )
Email: i Lc>oN J,.,to e M t Cj-(Js40,.. .„ . cct-A
Town of Queensbury Building&Code Enforcement Principle Structure Application Revised February 2017
' PROJECT INFORMATION:
TYPE: Commercial X id r:' I
WORK CLASS:
X Single-Family Two-Family Multi-Family(#of )
Townhouse Business Office Retail Hotel/Motel
IndustriaWVarehouse Garage(#of cars ) Other(describe )
STRUCTURE SQUARE FOOTAGE: GARAGE SQUARE FOOTAGE:
I.'floor: 0°13 ` 151 floor: —1 IS
2"d floor: cl 4 41 2"d floor:
3'floor:
Total square feet: 7 59
4th floor: "
Total square feet: 1 9 ? c
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ 2-6.0 Qt'e)
2. Proposed use of the building: s13.1ctu•- •
3. If Commercial or Industrial, indicate the name of the business:
4. Source of Heat (circle one): Oil Propane Solar Other:
(Fireplaces need a separate Fuel Burning Appliances& Chimney Application, one per appliance)
5. Are there any structures not shown on the plot plan? YES NO Explain:
6. Are there any easements on the property? YES NO
7. SITE INFORMATION:
a. What is the dimensions or acreage of the parcel? I
b. Is this a corner lot? YES 3
c. Will the grade be changed as a result of the construction? YES `NC '
d. What is the water source? PUBLI PRIVATE WELL
e. Is the parcel on SEWER or a PRIVATE SEPTIC system?
Town of Queensbury Building&Code Enforcement Principle Structure Apptation Revised February 2017
DECLARATION:
i. I acknowledge that no construction shall commence prior to issuance of a valid building permit and
work will be completed within a 12 month period.
2. If the work is not completed by the 1 year expiration date the permit may be renewed, subject to
fees and department approval.
3. I certify that the application, plans and supporting materials are a true and complete statement and/or
description of the work proposed, that all work will be performed in accordance with the NYS Building
Codes, local building laws and ordinances, and in conformance with local zoning regulations.
4. I acknowledge that prior to occupying the facilities proposed I, or my agents, will obtain a certificate
of occupancy.
5. I also understand that I/we are required to provide an as-built survey by a licensed land surveyor of all
newly constructed facilities prior to issuance of a certificate of occupancy.
I have read and agree to the above:
PRINT NAME:
4- � L 8
l
SIGNATURE: /�2�. DATE: Z 1 1
Town of Queensbury Building&Code Enforcement Principle Structure Application Revised February 2017
• Town of Queensbury Thomas R. Van Ness
Highway Superintendent
Highway Home (518) 745-0929
Department
742 Bay Road-Queensbury, NY 12801 David Duell
Phone: (518) 761-8211
Deputy Highway Superintendent
Fax: (518) 745-4466 Home(518) 743-0938
DRIVEWAY PERMIT
DATE: 3 I2z I tit
APPLICANT NAME: MICA-tl cLS Ciorm.P.
TELEPHONE NO.: 5t .bit .to31 t
ADDRESS TO BE INSPECTED: ((b 1-41u-s h�=
RETURN ADDRESS: I Y-1.S.
lAij -r
H msx ott t1Y
Applicant must show exact location and width of driveway(s) to be connected to the highway by
placing stakes at the specified location.
The Superintendent of Highways of the Town of Queensbury has reviewed this application. The
following action has been taken:
STEP 1: ( ) Preliminary Approval
NEED: ( ) Slight swale
( ) Deep swale
( ) Level with the road
( ) Level with the top of the paved wing
Size culvert pipe to be used (if necessary)
( ) 12" ( ) 15" ( ) 18" ( ) 24" ( ) 36"
Preliminary inspection completed by: Date:
Approval by Highway Supt: (or) Deputy Supt:
Upon completion, please resubmit this approved permit for a final approval
STEP 2: ( ) Final Approval ( ) Rejected
Date:
Thomas R. Van Ness, Highway Superintendent David Duel!, Deputy Highway Superintendent
FUEL BURNING APPLIANCE & Office Use Only
.104011
CHIMNEY APPLICATION Permit#: jt to t) •17-4(
Permit Fee:$
folk n of(Zycensbury
742 Bay Road, Queensbury, NY 12804 Invoice:#:
P: 518-761-8256 www.nueensbury.net
Project Location: \lb -7- Jr_ArdT bz. Tax Map ID#:
Room of Install: CI 17-0: Planned Install Date: 11--
**ONE APPLICATION PER APPLIANCE**
CONTACT INFORMATION:
• Applicant:
Name(s): MiC-tbs„ 4-1CA4a ,
Mailing Address, C/S/Z: NAttietc>tq Notakke.Ktc_vit_Let rs..tY 7-t1
Cell Phone: ( t ) Land Line: (
Email: JFW4.v.wz. tAe_KAQM.S.ctszrak .c.c*-1
• Primary Owner(s):
Name(s):
Mailing Address, C/S/Z:
Cell Phone: ( Land Line: _(
Email:
• Installer/Builder:
Business Name: TT -' MS( PP•Al 0
Contact Name(s): c_ireerA I-4M4ov=rvik
Mailing Address, C/S/Z: r7C46C) A-4--W111•44‘v", t•k-e 1220G
Cell Phone:_( ) Stcf=1"kek Land Line: _(
Email:
Contact Person for Building & Code Compliance: 17.-14(
LCPC-
Cell Phone: ( '5(b ) .3144- Land Line: (
Email: 1 LOCAP- C-10 CA-
Fuel Burning Appliance &Chimney Application Revised March 2017
•
FUEL BURNING APPLIANCE INFORMATION:
TYPE OF DEVICE:
Stove Fireplace Insert %4.Fireplace
_ Fuel Fired Equipment (Garage Only, 18" clearance per IMC 304.3)
) . Fireplace, factory built**
**Manufacturer's name: 4eP - p 1- Cfu> Model#:
SOURCE OF HEAT:
Wood Coal Pellet )4 Gas
CHIMNEY INFORMATION:
Masonry:
block brick stone
Flue:
tie steel size, in inches
Material*:
double-wall triple-wall insulated
(*Manufacturer's name: Model#: )
ADDITIONAL INFORMATION:
1. Two inspections are required. A rough-in inspection, prior to installation and a final inspection, after
installation.
2. Manufacturer's installation manual must be available at the time of inspection.
3. Masonry fireplaces & chimneys require plans to be submitted.
4. Twenty-four(24) hour notification is required for inspections.
Declaration:Construction/installation must conform to NYS Fire Prevention & Building Code and/or manufacturer
requirements. The applicant or owner agrees to comply with all applicable laws,ordinances, regulations and all
conditions that are part of these requirements and also will allow the inspector to enter the premises to perform the
required inspections.
I have read and agree to the above:
PRINT NAME: , (4.,I Z6 Gl c
SIGNATURE: "y - ' DATE: `'/I
Fuel Burning Appliance &Chimney Application Revised March 2017
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rtoki
SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
742 Bay Road,Queensbury,NY 12804
Tinvn<,fcZiccnshriry P:518-761-8256 www.eueensbury.net Permit#: QC-91 tot • (2.O Ili
Tax Map ID#: Permit Fee: $ ; Invoice#:
Project Location: 11L SaVtz r- Septic Variance? Yes No
Primary Owner(s) M\C.f c GL17-00P .F-kc t t r
Mailing Address I y1P c.,}..s,s I t Msri-11sd.�tCVi�� �,-� 12-1e,
Phone & Email e) .`ch1^1 Cc,-7c:11 e t-ii ci-oNi _sc,1 • CsD1-4
Installer/Builder -S 'F-TZM t �CGA�t, T1J�1Ct
Mailing Address IVb .,\ �} N,Y 1 Z2) 9
Phone & Email -51,2) • 4-7,'131
Engineer t�h-c� Et�l�►i 1._ i P.c
Mailing Address i tp ,Ly � 1- NY 12. 4
Phone & Email ` 1(7:6 •-7 q • .441..o�
Contact Person for Building&Code Compliance: 1 t'1-`r Phone: 51'3•`2)' - •314-4
RESIDENCE INFORMATION:
Year Built #of bedrooms X gallons per bedroom =total daily flow Garbage Grinder Yes
1980 or older Installed? (circle one)
1981-1991 Spa or Hot Tub Yes
Installed? (circle one)
1992-Present 2 ) ���
PARCEL INFORMATION:
Topography /Flat Rolling Steep Slope %Slope
Soil Nature ?e Sand Loam Clay Other
Groundwater At what depth? ek4
Bedrock/Impervious material At what depth?
Domestic Water Supply )Municipal _Well (if w II,water supply from any septic system absorption is ft.)
Percolation Test Rate: per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size /icc-Y gallons(min.size 1,000 gallons, add 250 gallons for each garbage cylinder or spa/hot tub
System Absorption field with#2 stone Total length ? ft.; Each Trench `5- ft.
Seepage Pit with#3 stone How many: ;Size:
Alternative System Bed or other type:
Holding Tank System Total required capacity? ; tank size ;#of tanks
NOTES: 1.Alarm system&associated electrical work must be inspected by a Town approved electrical inspection
agency; 2.We will no longer allow systems to be covered until such time as an as-built plan is received and approved.
The installed system must match the septic layout on file—no exceptions.
Declaration:Any permit or approval granted which is based upon or is granted in reliance upon any material
representation or failure to make a material fact or circumstance known by or on behalf of an applicant,shall be void.
have read the regulations and agree to abide by these and all requirements of the Town of Queensbury Sanitary Sewage
Disposal Ordinance.
PRINT NAME: 4,„,› 5 Gf G DATE: /12-4
SIGNATURE: DATE:
l
Town of Queensbury Building&Code Enfor ement Revised February 2017