applications Office Use Onl
Permit'
PRINCIPLE STRUCTURE PERMIT
Permit Fee: $
APPLICATION
Tioq7t of(Leensbu,,
742 Bay Road,Queensbury, NY 12804 y,Rec Fee: $
P:518-761-8256 www.aueensbury.net Invoice#: J�qqz`Db
Project Location: �ICpf/Y.KJ Lr(( l I,I^
Tax Map ID #: ��� - .� Subdivision Name: Ba"t'f ( i(�('p
Q
"TOWN BD. RESOLUTION 86-2013: $850 recreation fee for new dwelling units: single family,duplexes/two-family,
multiple family, apartments, condominiums,townhouses, and/or manufacture dular homes, but not mobile
homes. This Is In addition to the permit feels). 1E
1b
CONTACT INFORMATION: D
Ei
2 3 2011]
• A lica • 1. 1
Name(s): WI L� 1TOVM
Mailing Address, C S/Z: l ES
Cell Phone: f 51$ ) 561 of Land Line:
Email: rnLidr9 0,clmr; l.(,oan
• Primary Owner(s):
Name(s):
Mailing Address, C/S/Z:
Cell Phone: �_) Land Line: �)
Email:
• Contractor •
Business Name: �d LLC
ContactName(s): vj�n
Mailing Address, C/S/Z: It ,I tojcf ✓r. �/t•
Cell Phone: 1,9 ) 9.S-1 ci 6 Land Line:
Email:
• Architect(s)/Engineer(s):
Business Name: IF�1115 10 Il an< LIPS;Ja2, s
Contact Name(s): Vic,
Mailing Address, C/S/Z: ins Colon 5-1- CU.-,,s
Cell Phone: ( ,c51A ) '193. Alo8-1 Land Line: � )
Email:
Contact Person for Building & Code Compliance: 2L ca ��(l
Cell Phone: (iJ ) X0-1 '0 t 31J Land Line:
Email: l�c��m�\
Town of Queensbury Building&Code Enforcement Principle Structure Application Revised February 2017
PROJECT INFORMATION:
TYPE: Commercial Residential
WORK CLASS:
Single-Family _Two-Family _Multi-Family(#of units )
_Townhouse _Business Office Retail _ Hotel/Motel
Industrial/Warehouse _Garage(#of cars ) —Other (describe )
SQUARE FOOTAGE:
1 st floor:
2nd floor: 9gct
3' floor:
4" floor:
Total square feet: Q!Z; Z
ADDITIONAL PROJECT INFORMATION: �y
1. Estimated Cost of Construction: $ 0 (q '00,0 cc
2. Proposed use of the building:
3. If Commercial or Industrial, indicate the name of the business:
4. Source of Heat (circle one): Gas Oil Propane Solar Other C'De�II '' ZnC>Q
Fireplaces need a separate Fuel Burning Appliances&Chimney Application,one per appliance
5. Are there any structures not shown on the plot plan? YES 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. Will the grade be changed as a rest F he construction? YES
d. What is the water source? UBLI PRIVATE WE
e. Is the parcel on SEWER or a PRIVA SEPTIC system?
Town of Queensbury Building&Code Enforcement Principle Structure Application 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. Ifthework 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. 1 acknowledge that prior to occupying the facilities proposed 1, or my agents, will obtain a certificate
of occupancy.
5. 1 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: LA
SIGNATURE: . �_ /cSz�+ DATE: j 1
Town of Queensbury Building&Code Enforcement Principle Structure Application Revised February 2017
FUEL BURNING APPLIANCE & Office Use Only
a, CHIMNEY APPLICATION Permit#:
Permit Fee:$
limn al t Lrceushury
742 Bay Road, Queensbury, NY 12804 invoice:#:
P: 518-761-8256 www.gueensbury.net
Project Location: Tax Map ID #: A9l b' Z
Room of Install: Planned Install Date: r-201-7
**ONE APPLICATION PER APPLIANCE**
CONTACT INFORMATION:
• A li t:
Name(s 1: \�I Ain �e� t
Mailing Address C/S/Z: l� � ) ,�if Y!U fin= t �P P,v�t�l,��
Cell Phone:�) 30? 0130 J Land Line: �)
Email: (P8 Al ( 1 to n�
Primary Owner(s):
Name(s):
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line: _( )
Email:
Installer Builder:
Business Name:
Contact Name(s): N1
Mailing Address, C/S/Z:
Cell Phone:_( -j -`f,�L(c /�—Land Line: _( )
Email:
Contact Person for Building & Code Compliance: I p
Cell Phone: _(�(� ) 380-1 ula'o Land Line: ( )
Email: rA7K10 d2 cry G•l • ,rmn-
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: Model #:
SOURCE OF HEAT:
Wood Coal Pellet 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 af�ove:
PRINT NAME: �� I
SIGNATURE: DATE: 7
Fuel Burning Appliance &Chimney Application Revised March 2017
Ar'f&l11h'.i IL
SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
742 Bay Road,Queensbury,NY 12804
rnni Y'(hnrnahnm P:518-761-8256 �w/ww.gueensbury.net Permit#:
Tax Map ID#: alI �, p –I �� Permit Fee:$_____; Invoice#:
Project Location: t Septic Variance? Yes No
Primary Owner(s)
Mailing Address
Phone&Email t3ono L,3 i Q
Installer/Builder
Mailing Address
Phone& Email
Engineer
Mailing Address
Phone& Email I
Contact Person for Building&Code Compliance: \ Phone: Slg 3 DZ �CNQ
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 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 sorption field with# Total length `l o ft.; Each Trench (Z O ft.
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.
PRINT NAME: DATE:
SIGNATURE: DATE:
Town of Queensbury Building&Code Enforcement Revised February 2017