applications PRINCIPLE STRUCTURE Office Use Only
}3 PERMIT APPLICATION
,� Permit#: R 23t.
C--'t) - 7-0‘ J
Town of Queensbury Permit Fee: $ 16(0-'1 • €Z
742 Bay Road,Queensbury, NY 12804 *Rec. Fee: $ 4550
P: 518-761-8256 www.queensbury.net ,`.
/� Invoice#: -e_
Project Location: q 7 (R)O(OIC -A A 0 P y i 1.ex,kV roy' N 12-`6
Tax Map #: SD e( - 3 Subdivision Name:
TOWN BD.RESOLUTION 86-2013:$850 recreation fee for new dwelling units: single family,duplexes/two-family,
multiplefamily, 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): 'Da ${', IJ �v
Mailing Address, C/S/Z: Gil o,Oot(;(ru „ l t I I eG( 1-G-iaz 6- 9pe i\ I �ch`4
Cell Phope: ( i . ) -7 2:7 -73'4Q Land Line: ( ) `I
Email: a(/(Li Sc . La parkcp 9 nu i,
car yi
• Primary Owner(s):
Name(s): A,icyc, I' ? ir4 - 66 d f\---' _
Mailing Address, C/S/Z: Q7 i,J6p(ICVic.6(C 4-(+1( ro( I L4 _ &eary. FJ (2� -'
Cell Pho e: (St ct ria—/- 734401 1VAU I"h and Line: ( )
Email: iSe- . Lb par, Ah l• C -
1 Check if all work will be performed by homeowner only
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s):
Contractor Trade:
Mailing Address, C/S/Z: 171 LE C CE 11 V Imo°
Cell Phone: ( ) Land Line: (
Email: 12019 3
**List all additional contractors on the back of this form APR9 �
TOWN OF QUEENSBURY
• Architect(s)/Enqineer(s): BUILDING&CODES
Business Name: F-,{- n K 3.e l ir,
Contact Name(s): � 1 L. JP (
Mailing Address, C/S/Z:_2-7 K t�,i -Terrace , L.e 60/6 iv®P (2 tic
Cell Phone: ( J I T ) - j i to - '`S a i i Land Line: ( )
Email:
Contact Person for Building & Code Compliance: \rtM k= .16(1
Cell Pho e: (-5i$ ) 101P-Stall Land Line:
Email: e tie @ n . rY, (Orr\
OAnrinln CYRIrt11ro Darkest Revised February 2019
;PROJECT INFORMATION:
TYPE: Commercial X Residential
WORK CLASS:
Single-Family Two-Family Multi-Family(#of units )
Townhouse Business Office Retail Hotel/Motel
Industrial/Warehouse Garage(#of cars ) _ Other(describe )
STRUCTURE SQUARE FOOTAGE: GARAGE SQUARE FOOTAGE:
1ST floor: )9(044 S . r_ 1ST floor: —PP�..!
2"d floor: 14 2nd floor: (-4
3'floor:
Total square feet: )2 1
Basement(habitable space):
Total square feet: 2. O S F-
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ 30b r 06D
2. Proposed use of the building: I S i 0-1
3. If Commercial or Industrial, indicate the name of the business: N
4. Source of Heat: Gas Oil Propane Solar Other:
(Fireplaces need a separate Fuel Burning Appliances&Chimney Application, one per appliance)
S. Are there any structures not shown on the plot plan? YES 0 Explain:
6. Are there any easements on the property? YES I%O)
7. SITE INFORMATION:
a. What is the dimensions or acreage o e parcel?
b. Is this a corner lot? YES 0
c. Will the grade be changed as a result of the construction? 410 NO
d. What is the water source? PUBLIC PRIVATE y WELL
e. Is the parcel on SEWER or a PRIVATE SEPTIC system? f't kg/
Ravicad Fehruary 2019
DECLARATION:
I. I acknowledge that no construction shall commence priorto 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 lyear 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 H, or my agents, will obtain a
certificate of occupancy.
5. I understand that I/we are required to provide an as-built survey by a licensed land surveyor of
a II newly constructed facilities prior to issuance of a certificate of occupancy.
I have read and agree to the above:
PRINT NAME: 3eols-e., tkriotic
DATE: 31 P )11 SIGNATURE:
Prinrinla Stnirtitro Parktat Revised February 2019
Office Use Only
FUEL BURNING APPLIANCE & Permit#: Qom. —92 \ -204, j
•
"' `'"' ""' CHIMNEY APPLICATION
Permit Fee: $
x f;'
Invoice#:
742 Bay Road, Queensbury, NY 12804
P:518-761-8256 w ww.queensbury.net
Project Location: c'! i \IV DOCACM(LlL 1111 IcetTax Map ID: ` S-D ' I - 33
Room of Install: re-a„—f ,--,4- Planned Install Date: _Atit9 f,t-St
**ONE APPLICATION PER APPLIANCE**
CONTACT INFORMATION:
• Applicant:
Name(s): t ?e,f1+5Y
Mailing Address, C/S/Z: 1,0 odtcht.wic -H, fl i`r1
Cell Ph.:� ( 5k1 ) �12-7 -1 3'-kl3 Land Line: (
Email: t°�1'1 i . L,. P6T-74{1/0 LXT ;
• Primary Owner(s): �J
Name(s): l)f r>I Sc G ISC1(61 �t Mailing Address, C/S/Z: q 7 -)OJr;A bkc,k, HI( { IOC( , L&'' (iL'4'9e. N ( : z '-
_
Cell Ph.: (51 )1)--7-73-IC ��'$)321-?;I Land Line: ( )
Email: d i c;-('_. . f O r --@ 9rrvt,d . L O r
❑ Check if all work will be performed by homeowner only
• Installer/Builder: Workers' Comp documentation must be submitted with this application
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _(
Email:
Contact Person for Building & Code Compliance:
Cell Ph.: ( ) Land Line: (
Email:
Principle Structure Packet Revised February 2019
FUEL BURNING APPLIANCE INFORMATION:
TYPE OF DEVICE:
V Stove Fireplace Insert _ Fireplace
_ Fuel Fired Equipment (Garage Only, 18" clearance per IMC 304.3)
Fireplace, factory built**
(**Manufacturer's name: Model #:
SOURCE OF HEAT:
"Wood _Coal _ Pellet Gas
CHIMNEY INFORMATION:
_ Masonry (require plans to be submitted):
block brick stone
Flue:
tile _steel size, in inches
Material*:
double-wall triple-wall ' insulated
(*Manufacturer's name: LtAW54,i Model #: L )
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.
5. Workers' Comp insurance information is required with this application.
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:
O 2 _Z4(.-zvZU
PRINT NAME: bein I 123A ( � /� f �,�
SIGNATURE: -- �_ DATE: 3 19
. Revised February 2019
,' Office Use Only
FUEL BURNING APPLIANCE & Permit#: . ---On\ -2.Ok
(4,—....-;-., CHIMNEY APPLICATIONmsPermit Fee: $
?r Invoice#:
742 Bay Road,Queensbury, NY 12804
P:518-761-8256 ,::-' k,:q ueenshury.net
Project Location: 4-1 vocichttcLk 11 6Tax Map ID: cgSD - l- 3
Room of Install: Gft6UTF KOOr°\ Planned Install Date: A L i,L -E-
**ONE APPLICATI ON PER APPLIANCE**
CONTACT INFORMATION:
• Applicant:
Name(s): -1)e,tislISC iSd,l iv
Mailing Address, C/S/Z: q 1 10 OO1k 1(ASV_ kit 11 r4
Cell Ph.: _(15 % ) 1'2-7 131-40 Land Line: ( )
Email: ol.,P.en` v, . L. pay O. 1 M a..+ I . U
• Primary Owner(s): ,
Name(s): b'-ClI Sc + r,MOM Nc- 64 i rl
Mailing Address, C/S/Z: cl 7 t- O&ia ch(ALk. 1411 I I leek L o 1e ()al 0. 11 121 tic"
f
Cell Ph.: ( ► IC )1 7-7340 (5I9)\)3 %21- Land Line: _( )
Email: 1 V C' . L 6 pv� C� 9rniUI I . cory„
❑ Check if all work will be performed by homeowner only
• Installer/Builder: Workers' Comp documentation must be submitted with this application
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line: _( )
Email:
Contact Person for Building & Code Compliance:
Cell Ph.: _( ) Land Line: ( )
Email:
Principle Structure Packet Revised February 2019
a p
FUEL BURNING APPLIANCE INFORMATION:
TYPE OF DEVICE:
"Stove — Fireplace Insert _ Fireplace
Fuel Fired Equipment (Garage Only, 18" clearance per IMC 304.3)
Fireplace, factory built**
(**Manufacturer's name: `2e(e0GJ Model #: 3I OD
SOURCE OF HEAT:
"Wood Coal Pellet Gas
CHIMNEY INFORMATION:
Masonry (require plans to be submitted):
block _ brick _stone
Flue:
a _tile —steel size, in inches
Material*:
double-wall triple-wall insulated
(*Manufacturer's name: 1.-anaI Model #: LI 4 3 )
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.
5. Workers' Comp insurance information is required with this application.
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: 1)— I �j
SIGNATURE: ,rJ Lr F� DATE: 3 ) ID)
i�I
��.1C1/�'C
Principle Structure Packet Revised February 2019
' �.. Office Use Only
Town zz 11
Town ofC is sbury Permit#: -E_. -+ C2`x- � 11
SEPTIC DISPOSAL PERMIT APPLICATION Permit Fee:$ ; Invoice#:
Septic Variance? Yes No
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net
Tax Map ID#: <.� � ) 3
Project Location: 00CIG1 L d L01 & M� l 2 K
• Ap (cant:
Name(s): . 1
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _(
Email:
• Primary Owner(s):
Name(s): i� l c : 4' U tz` '176
Mailing Address, C/S/Z: �1
Cell Phone:_( ) Land Line: _(
Email:
❑ Check if all work will be performed by homeowner only
• Contractor: Workers' Comp documentation must be submitted with this application
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _(
Email:
• Engineer(s):
Name(s): Hutchills En fie
Mailing Address, C/S/Z: 1lOai 4-iOtel J ia;n-101 t o t 1 (tenc {� 1u°� IZgo4
Cell Phone:_( ) Land Line: _(-i ) 7�� - 0-))0
Email:
Contact Person for Building & Code Compliance:
Cell Phone: _( ) Land Line: (
Email:
Principle Structure Packet Revised February 2019
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms: X gallons per =total daily flow
per day bedroom Garbage Grinder Yes No
1980 or older 150 Installed? (circle one)
1981-1991 130 Spa or Hot Tub Yes No
Installed? (circle one)
1992-Present 110
PARCEL INFORMATION:
Topography Flat Rolling Steep Slope %Slope
Soil Nature _Sand _Loam _Clay Other(explain:
Groundwater At what depth?
Bedrock/Impervious material At what depth?
Domestic Water Supply _Municipal _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#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 and 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. 3. As-built drawings must be
submitted prior to the inspection, if there has been a change to the submitted plans.
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 abide by these and all requirements of the Town of Queensbury
Sanitary Sewage Disposal Ordinance.
PRINT NAME: 1 u t Se., 604-0A)„, DATE: 3- /.- 9
SIGNATURE: 01141)-k4j1g—e---k
r� DATE:
Principle Structure Packet Revised February 2019