applications • LJllll.e C.1SC'Lit ily
Permit##: /2 L ^U 6 E_o( f
PRINCIPLE STj';UCTURF PERMIT
APPL1C ECE0 v
Toren of Queensbury e"� `_.•;
742 :ay Road,Q eeaasbaary,P Y 12804 $ CJ C�
P: 518-761-8256 www.ziueensbury,net MAY 1 3 20 '1 „�, _ '.:; f.S l/
l'n �1jcct Location: —75 t hu - ' e-Ui 4EQUG &EENSBURY
CODES
Tax Map ID #: 3 0%, Subdivisi:•:n Name:
*T•wN 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):
Mailing Address, C/S/Z: 6 M tea- I44bJ 9`-'1 �z-V1l � , MI' 12-1 k�
Cell Phone: ( 5%1 ) Land Line: ( 53?) ) 'act:. (c
Email: --\ Mtte-- 2-Q. I"11C-Y �
• Primary Owner(s):
Name(s):
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: (
Email:
• Cintracti,r(s):
Business Name:
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: ( )
Email:
• Architect(s)/Engineer(s):
Business Name: kL*`.1 a 1" 7 e.
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: ( ) tarn 24 Land Line: (
Email: 1_ruF- 6 e tC PaiZAZ
Contact Person for ;:wilding & Csde Compliance: "T° ' ' w scsc)
Cell Phone: ( '`= ) c6S1.314-4 Land Line: (
Email: a LO “: M
Town of Queensbury Building&Code Enforcement Principle Structure Application Revised February 2017
PROJECT INFORMATION:
TYPE: Commercial
WORK CLASS:
X Single-Family Two-Family Multi-Family(#of )
Townhouse Business Office Retail Hotel/Motel
Industrial/Warehouse Garage(#of cars ) Other(describe )
STRUCTURE SQUARE FOOTAGE: GARAGE SQUARE FOOTAGE:
1ST floor: 0 1(6,(.9 Pn.1 Q s: (0'15 1ST floor: 21--
2'd floor: — 2nd floor:
3rd floor:
Total square feet: QUO 41.
4th floor:
Total square feet: 2 ,300 ct'
ADDITIONAL. PROJECT INFORMATION:
1. Estimated Cost of Construction: $ Z9-°/ a 06"
2. Proposed use of the building: L
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
7. SITE INFORMATION:
a. What is the dimensions or acreage of the parcel?
b. Is this a corner lot? YES C'�O)
c. Will the grade be changed as a result of the construction? YES NO
d. What is the water source? (PUBLI :- PRIVATE WELL
e. Is the parcel on SEWER or a PRIVATE SEPTIC system? `S---le-7\C--
Town of Queensbury Building&Code Enforcement Principle Structure Appication Revised February 2017
DECLARATION:
i. I acknowledge that no construction shall commence prior to issuance of a valid b u i Id i ng 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: 4t.41-1/0.--, 1- It3 C, 5Cib
SIGNATURE: DATE: _ 13
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
d Dl
742 Bay Road-Queensbury, NY 12801 Davi ua
Phone: (518) 761-8211 Deputy Highway Superintendent
Fax: (518) 745-4466 Home(518) 746-0938
DRIVEWAY PERMIT
DATE: =513r19
APPLICANT NAME: iv1CH AkELS CcizzOP LA-C-
TELEPHONE NO.: 52
ADDRESS TO BE INSPECTED: -1 5 WA-AzACT" H
RETURN ADDRESS: PaN4r-koT-4S
I
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 URNING APPLIANCE & Office Use Only
r CHIMNEY APPLICATION
Permit#: —U-251 1- 20\1
Permit Fee:$
town of(Zuccnsbw;v
742 Bay Road, Queensbury, NY 12804 Invoice:#:
P: 518-761-8256 vvww.ciueensbury.net
Project Location: '1 5 PILLS bQ Tax Map ID #:
Room of I stall: Citzx -r '2cvt. Planned Install Date:
**ONE APPLICATION PER APPLIANCE**
CONTACT INFORMATION:
• Applicant:
Name(s): tit ace-t scar �- s�t.l•"��, Li c.
Mailing Address, C/S/Z: l MI S L `< I+�I t���d��-�� �1`r ; zn
cis
Cell Phone: ( ) Land Line: ( )
Email: tAICA-tom ctst4
• Primary Owner(s):
Name(s):
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _( )
Email:
• Installer/Builder:
Business Name: TT °
Contact Name(s): Utz
Mailing Address, C/S/Z: l'76c) "-/, — 1120.5
Cell Ph ne:_( 51,c5 ) SA09 "Rem> Land Line: _( )
Email:
Contact Person for Building & Code Compliance: To4e
Cell Phone: ( SsQ, ) cz,S'D Land Line: (
Email: 'r LOc cao M.%c4tP •,se 1P%c
Fuel Burning Appliance &Chimney Application Revised March 2017
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: 1-1c - CrL Model#: (01--3®`ie;)
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: '^ � -063- (.(b
SIGNATURE: DATE: S ) /
Fuel Burning Appliance &Chimney Application Revised March 2017
• SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
742 Bay Road,Queensbury,NY 12804
rrnrn ofQ ccnabmy P:518-761-8256 Permit#: f-C '02.cr - tc)
ww�rv.s�saeensba�ry.�ne#
Tax Map ID#: Permit Fee:$ ; Invoice#:
Project Location: Septic Variance? Yes No
Primary Owner(s) t•A‘c,4043,s ,t t r
Mailing Address MAct1S Mt�\,tt -, 12.-t1c5
Phone & Email e), .`ici • tca7=11 e. t„6I4tD„E Sc.ige , cc -4
Installer/Builder �ip -� �t.��,ay (C.46,\L �c
Mailing Address Nplm11-‘ ;-{ ,
Phone & Email 74"7,
Engineer ►�l�cyci,y t, tUC� , P.c
Mailing Address ¶( l--tp\10-4\4.1 rz,> c NI, \2.t7 4
Phone & Email 51g o-7 445
Contact Person for Building&Code Compliance: '`-4``e LSx44SC.. Phone: 5t B •Cas'�1
RESIDENCE INFORMATION:
Year Built #of bedrooms X gallons per bedroom =total daily flow Garbage Grinder Yes co
1980 or older Installed? (circle one)
1981-1991 Spa or Hot Tub Yes Wo
Installed? (circle one)
1992-Present 7/ 3 3 0
PARCEL INFORMATION:
Topography X Flat Rolling Steep Slope %Slope
Soil Nature \e Sand Loam Clay Other
Groundwater At what depth? /(1/0-
Bedrock/Impervious material At what depth?
Domestic Water Supply X Municipal _Well (if ell,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 /O_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 /5-0 ft.; Each Trench co- 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: giLL
DATE: (1
SIGNATURE: 7 � DATE:
Town of Queensbury Building&Code Enforcement Revised February 2017