application Office Use Only
Permit#: - 65\O' ZOt.
PRINCIPLE STRUCTURE PERMIT ,��
APPLICATION Permit Fee:$ Z
Town ofQyeansbur rDo
*Rec Fee:$ 7
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.aueensbury.net Invoice#: '
Project Location: A. , L ..c:
Tax Map ID #: 1 K \ `" / Subdivision Name:
*TOWN Bp.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, CJS/Z: c
Cell Phone: ( ) Land Line: ( S CT) � 7. 7 7
Email:
Primary Owner(s):
Name(s): C `--=
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: ( )
Email:
• Contractor(s):
Business Name:
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: (
Email:
• Architect(s)/Engineer(s):
Business Name: CA
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: (
Email:
Contact Person for Building& Code Compliance: _C i _' ( t`
Cell Phone: ( ) Land Line: J �}
Email:
Town of Queensbury Building&Code Enforcement Principle Structure Application Revised February 2017
PROJECT INFORMATION:
TYPE: Commercial esidentiai
WORK CLASS:
Single-Family Two-Family Multi-Family(#of )
Townhouse Business Office Retail Hotel/Motel
Industrial/Warehouse Garage(#ofcars ) Other(describe )
STRUCTURE SQUARE FOOTAGE: GARAGE SQUARE FOOTAGE:
1sT floor: t 1ST floor: ,2 ‹f
2"d floor: 2"d floor:
3rd floor:
Total square feet: — (t,
4th floor:
Total square feet: ,, \-7 (,e"
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ ��;��; T'C.,
2. Proposed use of the building: 1,,. , e.s_ C -..- E - ..C1
3. If Commercial or Industrial, indicate the name of the business:
4. Source of Heat (circle one: Gas . 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 rr NO Explain:
�C'y
6. Are there any easements on the property? YES NO
7. SITE INFORMATION:
a. What is the dimensions or acreage ojthe parcel? ,� � "'� e: t._re- -�
b. Is this a corner lot? YES NO
c. Will the grade be changed as a result of the construction? YES NO
d. What is the water source? ( PUBLIC PRIVATE W
e. Is the parcel on SEWER ora PRIVATE SEPTIC sysjem?
C Principle Structure Apptatscn Revised Fetr;. ^1-
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. 1 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.
S. 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: A DATE:
Town of Queensbury Building&Code Enforcement Principle Structure Application Revised February 2017
_
..a
SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
742 Bay Road,Queensbury,NY 12804
Town on ucn Burl' Permit#: —92%0 - lc tt
P:618-761-8256 www.queensbury.net
Tax Map ID#: •"- k a k — —L— f Permit Fee:$ ; Invoice#:
Project Location: \"' ' £--._ -:f 't:7D C.-.-',tj Septic Variance? Yes No
Primary Owner(s) ' ,,_ �: . ( (.- re .- i- ( ,f
Mailing Address c. '
Phone& Email
Installer/Builder
Mailing Address --. , `.-
Phone & Email ` QK .,.t*
Engineer
Mailing Address
Phone & Email
Contact Person for Building&Code Compliance: k,,. (---s. r- r---" Phone: ( I < ' .t
RESIDENCE INFORMATION:
Year Built #of bedrooms X gallons per bedroom =total daily flow Garbage Grinder Yes N
1980 or older Installed? (circle one)
1981-1991 Spa or Hot Tub Yes No',, s
Installed? (circle one)
1992-Present \( -, -,
PARCEL INFORMATION:
Topography flat Rolling Steep Slope %Slope
Soil Nature and Loam Clay Other
Groundwater _ At what depth?
Bedrock/Impervious material At what depth?
Domestic Water Supply >llunicipal _Well (if well,water supply from any septic system absorption is ft.)
Percolation Test I Rate: per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FO NEW CONSTRUCTION:_
Tank size ' ---gallons(min.;si ,e 1,000 gallons,add 250 gallons for each garbage cylinder or spa/hot tub
System Absorption field with#2 stone ' -Taal length '`^-. ft.; Each Trench - ft. ~tip
I 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. I
have read the regulations and agree to abide by these and all requirements of the Town of Queensbury Sanitary Sewage
Disposal Ordinance.
f
:::::
°/; U DATE:
Town of Queensbury Building&Code Enforcement Revised February 2017
Town of QueensburyThomas R.Van Ness
Highway Superintendent
Highway Home(518)7+5-0929
Department
David Duell
742 Bay Road—Queensbury,NY 12801
Phone: (518) 761-8211 Deputy Highway Superintendent
Fax: (518) 745-4466 Home(518)748-0938
DRIVEWAY PERMIT
DATE: '5 7`?f( 1
APPLICANT NAME: CA
TELEPHONE NO.: L �''L> `7c-i�_7 ,?7.7
1
ADDRESS TO BE INSPECTED:
RETURN ADDRESS:
ct
•
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.
S i tP 2: () Final Approval ( ) Rejected
Date:
Thomas R.Van Ness, Highway Superintendent David Duell, Deputy Highway Superintendent