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applications r x / 4,1'111 PRINCIPLE STRUCTURE Office Use Only PERM RlVlyi _ ' P�PEFFy _.., (� D CEf! WE Permit#: At ® 1� N' 2vs -( _may �p Ibwrl (if(Zueensbury Permit Fee: $ 5, /!/ 742 Bay Road, Queensbury, NY 12804 MAY 2 9 2019 *Rec. Fee: $ % , U® P: 518-761-8256 www.queensbury.net TOWN OF QUEENSBURY Invoice#: I �)c L BUILDING& CODES Project Location: LOT s Tax Map #: 9 /a-62 -/,92 Subdivision Name: 3-1/4Z(eel C, n-E, crtij/p, -7,1—a-o/i1 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): PBSR bill L L C Mailing Address, C/S/Z: /0 ii/ZG/ 7- Sr Cell Phone: ( 'J/y. ) ?IJ ,3s/Z Land Line: ( ,c/? ) 79- 63/‘ Email: ,S70 CR Rd?ike e90L.> Ca f • Primary Owner(s): Name(s): P/EtLp 6 RUsSezL , PEA/A/Lc AlooRr Mailing Address, C/S/Z: S;94e Cell Phone: ( ) 542ie Land Line: ( ) Email: ,s-444e ❑ 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: Cell Phone: ( ) Land Line: ( ) Email: **List all additional contractors on the back of this form • Architect(s)/Enqineer(s): Business Name: E...V IS 4 WZLLZ44/S Contact Name(s): NAWY wzdzi-ifrlos Mailing Address, C/S/Z: s0 j 6-eiU t— 6—it—kJ FA des, NY /2 o/ Cell Phone: ( ) Land Line: ( ,:.5`/? ) 79,p yei7 Email: lurttloviisfy LL miwz-icAg, ee,44 Contact Person for Building & Code Compliance: 1'//.11 /?t1sSaL e/ pr',r>.S ,iicom Cell Phone: ( 7/1 ) F73 3 y, Land Line: (Sir ) 7?2 ,5-,34' Email: 5T0146'( co#tr( A01, cc/1i Principle Structure Packet t n • Contractor(s): Workers' Comp documentation must be submitted with this application Contractor Name(s): RicR A Gc x E CXCAuq o// Contractor Trade: E7rc9U,9-ttox/ Mailing Address, C/S/Z: QvrT/LMrLK r4Lt.s id kd 7 Cell Phone: ( 3-44 ) 7 ?( 730 Land Line: (s-'i? ) 791',,CI Email: • Contractor(s): Workers' Comp documentation must be submitted with this application Contractor Name(s): LJB C®A/Gj2cre,,L t C Contractor Trade: 1=purvD47,)rv_` Mailing Address, C/S/Z: /7? MpLock powv 12 Cell Phone: ( ) Land Line: ( Email: Z.Td Ce,vce' e / 9 I-MA.2'L ,c©.M • Contractor(s): Workers' Comp documentation must be submitted with this application Contractor Name(s): ShAQ1"LEv6Z Cb,u..sr/2vc�.r0/t/ Contractor Trade: Fj4Me2 Mailing Address, C/S/Z: c V ib72C// Rh Cell Phone: ( 3 /? ) 26/ 0900 Land Line: (3--/g ) 71/7 63/o Email: • Contractor(s): Workers' Comp documentation must be submitted with this application Contractor Name(s): DA112 y 1PA7TM Contractor Trade: EtEc7/2rct-4U Mailing Address, C/S/Z: Cell Phone: (Sig ) 36/ 7j50 Land Line: ( Email: • Contractor(s): Workers' Comp documentation must be submitted with this application Contractor Name(s): Contractor Trade: l2tVwALL Mailing Address, C/S/Z: Cell Phone: ( ) Land Line: ( Email: • Contractor(s): Workers' Comp documentation must be submitted with this application Contractor Name(s): Contractor Trade: Mailing Address, C/S/Z: Cell Phone: ( ) Land Line: ( Email: �_. i c._.. ... i. . Reviced February 2019 PF OJEC`'F 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: PT floor: /sS'6"7 :st F7 PT floor: 2"d floor: 2nd floor: 3rd floor: Total square feet: '70 S9 Fes" Basement(habitable space): Total square feet: /6-6 7 St ADDITIONAL PROJECT INFORMATION: 1. Estimated Cost of Construction: $ /0?S,OOO 2. Proposed use of the building: SEC 3. If Commercial or Industrial, indicate the name of the business: 4. Source of Hea . Gas Oil Propane Solar Other: (Fireplaces nee -a separate Fuel Burning Appliances & Chimney Application, one per appliance) 5. Are there any structures not shown on the plot plan? YES VO Explain: 6. Are there any easements on the property? YES NO 7. SITE INFORMATION: a. What is the dimensions or acreage of the parcel? 1t22x /AS— d b. Is this a corner lot? YES O c. Will the grade be changed as a res t of the construction? YES 0 d. What is the water source? PUBLI PRIVATE WELL e. Is the parcel on SEWER or a PRIV ATE SEPTIC system? pRxVA1 SEP`TZC PrinrinIP ctrnrtura Parkat o...a ..a�..H...�...�no t DECLARATION: I. I cknowledgethA no construction shall commence prior to issuance of a valid building perm and ,:,orK will be completed within a 12 month oeriod 2. If the work is not completed by the 1year expir-rtion cite the permit may be renewed subject to fees and department approval. 3. I certify that the ..pplication, plans and supporting materials are a true ..ind complete statement and/or description of the work proposed, that ..11 work will be performed in .zecordance with the NYS Building Codes, local building laws and ordin-mces, and in conformance with local zoning regulations. 4. B acknowledge that prior to occupying the facilities proposed I, sr my agents, wi obtain a certificAe of occupancy. 5. I understand that Owe are required to provkle as-built survey by a licensed land surveyor of ne,fly constructed facilities prior to issuance of certificate of occupancy. I have read and agree to the above: PRINT NAME: & rp6 Ri/SSe/ Pe/t1/1,Tj Dig‘ SIGNATURE: DATE: SAP//9 n -I a Rpvicori Fehr-Hark/?Mg , Office Use Only r. ‘ FUEL BURNING APPLIANCE & Permit#: —D' gj `2'0ti itlit i.lor a 4 44 CHIMNEY APPLICATION Permit Fee: $ r Invoice#: 742 Bay Road, Queensbury, NY 12804 P:518-761-8256 Project Location: 20% ,}5f //�.? c; EZ', ' Tax Map ID: Room of Install: .4rt, K, . 61,62,,i Planned Install Date: **ONE APPLICATION PER APPLIANCE** CONTACT INFORMATION: • Applicant: Name(s): ./??'AJ/J/ ,5 Nou r�6,E.P"/ e Z_C, Mailing Address, C/S/Z: be e 1, it.,c i/ ` a / pt i /t4 /Z9,4; Cell Ph.: (74 ) k 73 ' 5 '/z-- Land Line: ( ) Email: ,1-T,ed,; /1e7D, 6. ,e;',9/.c= .,--1 • Primary Owner(s): Name(s): Mailing Address, C/S/Z: Cell Ph.: ( ) Land Line: ( ) Email: ❑ 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: 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: 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. 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: SIGNATURE: DATE: Principle Structure Packet Revised February 2019 Town of Queensbury David Duell Highway Superintendent Highway f 518-7 61-8212 Department 742 Bay Road —Oueensbury, NY Mark Benware 12801 Deputy Highway Superintendent r � .�� p y gway P Phone: (518) 761-8211 518-761-8210 Fax: (518) 745-4466 DRIVEWAY PERMIT DATE: Sid 6/r 9 APPLICANT NAME: PCg D/t , L I C TELEPHONE NO.: NS) k73--3StA7 ADDRESS TO BE INSPECTED: Ldrer ESN'1Lau! C,25Pk/2i) RETURN ADDRESS: 374/11 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: Q Preliminary Approval NEED: ( ) Slight swale ( ) Deep swale C) 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: David Duell, Highway Superintendent Mark Benware, Deputy Highway Superintendent ti Office Use Onl _p�$ .SEPTIC DISPOSAL PERMIT APPLICATION Permit#: t Permit Fee: $ ; Invoice#: n>„�of cLecr stiury Septic Variance? Yes No 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.queensbury.net Tax Map ID#: -- 2 - 1 �- Project Location: ,j 3 %/ I r e. f' , ..- • Applicant: Name(s): z riG Mailing Address, C/S/Z: 41 t/;-e--,� e/fe'k`' /24'c ,, Cell Phone: _(2/1' ) 7 3 - 35- Land Line: _( Email: �. r'4s: acr ,ce 014 • Primary Owner(s): Name(s): 1 ,fl Mailing Address, C/S/Z: 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): Zic l�" �'�- •• 5 Contractor Trade: Mailing Address, C/S/Z: Cell Phone: _( ) Land Line: _( Email: • Engineer(s): Name(s): Mailing Address, C/S/Z: Cell Phone: _(_ ) Land Line: _( Email: Contact Person for Building & Code Compliance: Cell Phone: ( ) Land Line: ( Email: Septic Aonlication Revised Fehruary 7019 f 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) --Th 1981-1991 130 Spa or Hot Tub Yes() Installed? (circle one) ---....---�` 1992-Present 110 1 e .-7 7� 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: i—6 per minute per inch (test to be completed by licensed engineer/architect) PROPOSED SYSTEM FOR NEW CONSTRUCTION: Tank size /0e 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 200 ft.; Each Trench ,y C`7 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: _;)!-,. i<1!/ / , l?j1 a DATE: 7 e ; .1 l�7 j SIGNATURE: '`- 4 -e,, 14--/f, f, �,..�' / DATE: ��, ,' 47js l SPntic Annlicatinn Raviced FPhruary 7n19