applications ,
Office Use Only
05a
9- - ) • 2-0A
1,1t.r:os-7 PRINCIPLE STRUCTURE PERMIT Permit#: Z.
Permit Fee: $ -1-" (r)• c"- 0
APPLICATION
*Rec. Fee: $ INI4N-
742 Bay Road Queensbury, NV 2804
P 518-761-8256 Invoice#: Olee)
Project Location: IS et*.44(90, 1-464
Tax Map #: /VI •Its --A-4p Subdivision Name:
TOWN BD.RESOLUTION 86-2013 $850 recreation fee for new dwelling units single farm' , du es/two-family,
multiple family apartments condominiums townhouses,and or m (- r ite b t not mobile
homes. This is in addition to the permit fee(s).
RE
CONTACT INFORMATION:
AUG 16 2018
• Applicayt_
TO
Name(s): 310 V
Mailing Address, C/S/Z: taw S7til c (A,S FINQGurcNosDBEusRy
, al ti//00(
BUILDING
Cell Ph.: ( ) Land Line: (5lq, ) letb.-46.01
Email: kY1/41A &WO-OLAND V)11Aithipt,c (.614 .P..C. CelA
• Primary Owner
Name(s): b4thi)
Mailing Address, C/S/Z: 4/00 it-2011,ek f)&11) ---941) , ak.r.. 011/ IN Y mOet
Cell Ph.: _(t00 ) 14-06r27 DtithOf Land Line: (t ) 13 it/- -17G- .
Email: NIODIAt\IS1.959 @,6Af\ktii, Cod\
• Contractor(s):
Name(s): \)1k-t•\ 144g2...„
Mailing Address, C/S/Z: 4/4 110114 MY/ 6t/06 ?Oa , ith.kgNakIWI 1/1)01
Cell Ph.: _(°M. ) (PIA .€40/// Land Line: ( )
Email: illeiltf-a,t,(..-t, 4()TAA,MA,. CM
• Architexct(s)/Enaineer(s):
Name(s): Uht031 iltAAtitk.c
Mailing Address, C /Z: MCI &WI Ci?" t 6trol\Lc St / ((( 1400 (
Cell Ph.: ( ) Land Line: (
Email: kvA___LVM112AAMSAtsaUzUkALW/K2_KrsigiSjat\________
Contact Persri )for Building & Code Compliance: \-#U AMILPIL
Cell Ph.. (
Itor 011A -9/11/04/ Land Line: ( )
Email: lAgibti.16L ct, k6fitAigt/. UN\
,
PROJECT INFORMATION:
TYPE: Commercial Residential
WORK CLASS:
Single-Family Two-Family _Multi-Family(#of )
Townhouse Business Office Retail Hotel/Motel
IndustrialAA/arehouse Garage(#of cars ) Other(describe )
STRUCTURE SQUARE FOOTAGE: GARAGE S UARE FOOTAGE:
isT floor: 792 1sr floor:
2nd floor: /7 1) 1 2nd floor:
3'floor:
�1
Total square feet:
Basement(habitable space): 610
Total square feet: / Q 6
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ &400f000 ,
2. Proposed use of the building:1-VC-AD-VgC*,
3. If Commercial or Industrial, indicate the name of the business:
4. Source of Heat(circle one): Gas Oil - pane Solar Other:
(Fireplaces need a separate Fuel Burning Ap ' ces&Chimney Application,one per appliance)
5. Are there any structures not shown on the plot plan? YES O plain:
6. Are there any easements on the property? YES 4i,
7. SITE INFORMATION:
a.What is the dimensions or acreage of the parcel? .. €f GPc
b. Is this a corner lot? YES 0
c. Will the grade be changed as a resu- of the construction? Ca) NO
d.What is the water source? PUBLIC PRIVATE4 EL
e. Is the parcel on SEWER or a PRIVATE SEPTIC system? -1AiO,
DECLARATION:
I. I acknowledge that no construction shall commence priorto issuance of a valid building
perm 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 t rue 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 understand that Ikve are required to provkle 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: DATE: 6- •
Office Use Only
FUEL BURNING APPLIANCE & Permit#: 4‹ _Q15 60 -2-QM
(,) CHIMNEY APPLICATI ON Permit Fee:$
Invoice#:
742 Bay Road. Queensbth 12804 P.
518-761-8256
Project Location: 604,1511/1 (skAre, Tax Map ID: fA31.1t -
Room of Install: 6-Fre1cT 2voisiNs, Planned Install Date: TSD
**ONE APPLICATION PER APPLIANCE**
CONTACT INFORMATION:
• Applicant:
Name(s): '0401•11 WItAAA-Akc
Mailing Address, C/ /Z: GCVO. ;i1Obe-C62tFAS rAtt,S, 1\i4( (
Cell Ph.: _( Land Line: ( e, ) 1,1Q 0 ta-7
Email: ilkt• WIUAAAAS iD WilitAllmSvp,Ct&-i44-c, (kV\
• Primary Own s
Name(s): 'OM !IA) •WALIN
Mailing Address, C/S/Z: /1/190 k2oti,D Nlre--fiNjSW-`( 144
Cell Ph.: ( Land Line: _(
Email:
• Installer/Builder:
Name(s): 4C-1,0T t1,4
Mailing Address, C/S/Z:
Cell Ph.: _( Land Line: (cle, ) -7192, 7710
Email:
Contact Person for Building & Code Compliance:
Cell Ph.: alai-0. )0`2--- Land Line: (
Email: t4 TIVVIA/ GOI\
Town of Oueensbury Bulithn Indr,Enforcement
FUEL BURNING APPLIANCE INFORMATION:
TYPE OF DEVICE:
Stove sl\, Fireplace Insert Fireplace
Fuel Fired Equipment(Garage Only,'B"clearance per IMC 304.3)
Fireplace, factory built**
** Manufacturer's Name: -WO Model#:
SOURCE OF HEAT:
Wood Coal Pellet
CHIMNEY INFORMATION:
_Masonry:
block brick stone
Flue:
tie steel size,in inches
Material*:
double-wall triple-wa li insulated
(*Manufacturer's rri 4E3e = Model#:
ADDITIONAL INFORMATION:
1 Two inspections are required. A rough-in nspection,prior to installation and a final nspection,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 E required for nspections.
Peclaration:Construction/installation must conform to NYS Fire Prevention&Building Code and/or manufacturer
req uiements.The applicant or owner agrees to comply with all applicable bws,ordinances,regulations and all
conditions that are part ofthese 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 O \ k1A&
.�i�
SIGNATURE : GATE.
Fuel BumingAppliance /ht �t1��
imney Appli'.. ion
--y--, ./ SEPTIC DISPOSAL PERMIT APPLICATI ON
e------ Office Li-3e Onl
......;
74 Bay Road,Queensbury, \Y ll'x04
P 518-76 i-s.56 Perm;
Tax Map ID#: Le261 •1°'..V72 Permit , ,--,-,,
Project Location: e i
Primary Owner(s)
ql i)
Mailing Address /6(0 ilnitta.. 0 a ( ozaowttalvf\Nii 14424
Phone & Email w.-riii,-1/Ve 0 kiWitJ11/5r1 GiciAktlit
Installer/Buiider tl\i ItAtat .
Mailing Address ,..0 00. .fikvjoces 6,0u6 -F4,4191 hk1qvt2.0c. I I,Ng vlie.p
Phone & Email 1(4. 1 42'1/04/ thatfa.t, oi 40-(11/14 IL. taN\
Engineer TOK t )1CitLS
Mailing Address .(c)t ilAVkkikti,\D fh() tQW144Wiffl 1 NI 1%04
Phone& Email tnt9.1 4c-ofor "gut 5 Eikiliciig 'hi efltkiftia-ttlf,
_
Contact Person for Building&Code C•om p I iai n ce: Phone: '1(4-61A-tilio11/
RESIDENCE NFORMATION:
Year Built #of bedrooms X gallons per bedroom = totaldaily flow Garbage Grinder Yes 0
1380 or older Installed? {circle one)
— 4 1981-1391 Spa or Hot Tub Yes 0
Installed? {circle one) _
1392-Present-
/1// tin
PARCEL NFORMATION:
Topography J.i ea-IR 9.9.....01 _
Steep Slope %Slope
Soil Nature V_Sand _Loam ___Clay _Other
Clay Other
Groundwater At what depth?
Bedrock/lrnpery bus material At what depth?
Domestic Water Supply ____Municipal _Well{if well,water supply from any septic system absorption is ft.)
Percolation Test Rate:1.,c per minute per tic h{test to be completed by licensed engleer/arcttect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size 0,to gallons{min.size 1000 ga lions,add 250 gallons for each garbage cylinder or spa/hot tub
System Absorption field with#2 stone Total length 4o(Art ft.;EachTrench voive4 ft. I di (A104,
Seepage Pit with#3 stone How many: -Size:
Alternative System Bed or other type:
HoldingTank System Total required capacity? -tank size ;# of tanks
NOTES:1.Atarm system&associated electrica(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.l
have read the regulations and agree to abide by these and all requirements ofthe Town of Queensbury Sanitary Sewage
Disposal Ordin-nce.
1
PRINT NAME: k, tht , ikik3 DATE. c.*,i ,
. . .....e:
SIGNATURE: 1
DATE: bvtit"its
, i,
Town of Queensour,, EL 1 ,&Cooe Enfor - ,-nt