applications Office Use Only
Permit#: 2.G " 0 ►clb •2911
ikl
PRINCIPLE STRUCTURE PERMIT
APPLICATION
Permit Fee:$ �419 - Lo
Town of Queensbury Q
742 Bay Road,Queensbury,NY 12804 *Rec Fee:$
P:518-761-8256 www.queensbury.net Invoice#: I trt-
Project Location: '. -7 0 Croy—c ,�,,� �
Tax Map ID #: 7 9 7 „ k — @ ik-7 Subdivision Name:
*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): \,,j V c -ice---�, 7 , cc' .
Mailing Address, C/S/Z: (-1,--Q--1, �
Cell Phone: ( ) Land Line: (51 ' ) 7 —7. 77
Email: 0 c\,..ti. . ( ,,2.)c-i_
,
• Primary Owner(s):
Name(s): -. t—e_
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: ( )
Email:
• Contractor(s): 5tECE [IV21
Business Name:
Contact Name(s): Uii APR ' 1 r20T11
Mailing Address, C/S/Z: 3
Cell Phone: ( ) Land Line: 41 : . ..LL .
Email: �..
• Architect(s)/Engineer(s):
Business Name:
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: ( )
Email:
Contact Person for Building & Code Compliance: \____C
Cell Phone: (`" )3,.,�- t, t ;Z-'3E' Land Line: 1 )ter . "1_-
Email: c_L.: €<.--: -ec- _-F ,- �__ t. C- -t
Town of Queensbury Building&Code Enforcement Principle Structure Application Revised February 2017
PROJECT INFORMATION:
TYPE: Commercial Residential
WORK CLASS:
Ingle-Family Two-Family Multi-Family(#of )
Townhouse Business Office _Retail Hotel/Motel
IndustrialNVarehouse Garage(#ofcars ) Other(describe )
STRUCTURE SQUARE FOOTAGE: GARAGE SQUARE FOOTAGE:
1sT floor: Zj lsT floor:
2"d floor: 2nd floor:
3rd floor:
Total square feet:
4th floor:
Total square feet: ?,
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ \ 9` 1°00
2. Proposed use of the building:
3. If Commercial or Industrial, indicate the name of the business:
4. Source of Heat (circle one): as 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 din:
6. Are there any easements on the property? YES NO
7. SITE INFORMATION:
a. What is the dimensions or acreage -parcel? L-ft <DC
b. Is this a corner lot? YES C
c. Will the grade be changed as a res construction? YES NO
d. What is the ee? PUBLI PRIVATE WELL
e. Is the parc on SEWER a PRIVATE SEPTIC system?
Town o,Queensbury Building&Code Enforcement Principle Structure Apptation Revised February 2017
DECLARATION:
1. 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:
SIGNATURE: DATE: L-1/. .► t C*
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)7+3-0938
DRIVEWAY PERMIT
DATE: +
APPLICANT NAME: •
TELEPHONE NO.: f`4) - 79
ADDRESS TO BE INSPECTED: A � 1,,
RETURN ADDRESS: (. r•.
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 Duell, Deputy Highway Superintendent
'. SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
742 Bay Road,Queensbury,NY 12804
Timm of(bc nshurr
P:518-761-8256 www.queensbury.net Permit#: .
Tax Map ID#: 97 a 4 — b— \-7 Permit Fee:$ ; Invoice#:
Project Location: \-7 -Ca,,;, i2$.. Septic Variance? Yes No
Primary Owner(s) C \3\e
Mailing Address
Phone& Email ( 5 l 7cy_ --7 2-77 .,o Ne___ — `'
Installer/Builder CIL 4%
Mailing Address
Phone & Email c
Engineer c C__.-,, -- "-- -. ,."'N
Mailing Address 4-2k , E 1
Phone& Email ' <
Contact Person for Building&Code Compliance: Lc: Phone: " 4 2` ;?›
RESIDENCE INFORMATION:
Year Built #of bedrooms _ X gallons per bedroom =total daily flow Garbage Grinder Yes No
1980 or older Installed? (circle one)
1981-1991 Spa or Hot Tub Yes No
Installed? (circle one)
1992-Present
PARCEL INFORMATION:
Topography Flat Rolling Steep Slope %Slope
Soil Nature Sand Loam Clay Other
Groundwater At what depth?
Bedrock/Impervious material At wFyat depth?
Domestic Water Supply _�unicipal _Well(if well,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 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 ft.
Seepage Pit with#3stone 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. I
have read the regulations and agree to abieby`tiieseand all requirements of the Town of Queensbury Sanitary Sewage
Disposal Ordinance.
d DATE: t t T•
PRINT NAME: .,�'�----�'�f`" � � i
SIGNATURE: DATE: VA kA rJ
Town of Queensbury B Idi g&Code Enforcement Revised February 2017