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APPLIPA t I ON JUN 1 2 2018elfirrierr-- v-t— ,
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Rcjee'C'.. 5 35-1 -00
1742 Bay Road Oueensbury. NV '2804
;P 518-781-8256 -0
.1 40 , -•-it,i p, Fol 6:4,:.3,---,,-- r--, ,invoice ft; 0`:;-'c, 3
7, •0 ,-,:•:- •):4,,z1..__ ,___I____-_':-'-'' '_-_-';:":1-t---7-j1,- _ L Project Location: eatiet Oat' 'Celia kg• Rt06-E7 gb Tax Map #:141110111111111111111111110.54- l' '7%"D'u - '- Subdiion Name: 'PANT P-ito6-6- . .
TOWN BD RESOLUTION$6-2013 Sl350 recreation fee for new dwelling un ;•:. f 1,...;,:-::;: f.:-.i.;',1}.--, dpp - . two-family,
multiple fatni ly apart-,•••,',.:::-.,tii c-;orido:1-,rliu[-is zow,,ht:..u-i.,;.?:1-_, and or manufactured .-,..: roojular homes I:it..it not,,15):,,...,;,::.
homes this is in addition to the permit fee(s).
CONTACT INFORMATION:
p,.....ealcant:
Name(s): c:t:.)0 1-11 I Li,... 5 1.0 L.1) E.,R.S o E t-4•v.(--t)
CZ-
Mailing Address, CISIZ: q troutJ tV5 IOC bR I vL-7- 0.1.4E0-66 4:1 iv'," 124-0 Li
cerl Ph.: I ( s-i.T ) -711i - ici 33 Land-LiA' e: I (s-tr ) -7 6-.3.s--2,0 (cco,-)
Email: Fo to 0... 5 Deg.4 NV 0 G-rn A ipi\
0 Primary 0:Viner(s):
Name(s): SAIY)6" • AS !I PPLic,AN 1-
Mailing Address, CISIZ:
Cell Ph.: ( Land Line: J ) 0.
,
Email: -_.
0 ContrattOriat
Name(s): . . S A me- As A P 19 Lt cekt-J71- . .
Mailing Address, CISIZ:
Cell Ph.: ( ) Land Line: ( )
'Email:
tabittzsogrkatgt ernipto tAilt_t_ 13q Doc ovc G-LENs Few-s pi
Name(s): _ ,4 ..• 0 146 i
Mailing Address, C/S/Z: -
Cell Ph.: ( ) , I and Line: 1 (c-t? ) -..404i0Og2F21- -.1q I -0 241
Email: , EV tiA1-4- W i(\
Contact Person for Building &COde Cornpliance: .3-PC LC tk i
Cell Ph.; 1 .(S-t? ) 1'11- 19 3 ttafitt Linel I (s-I? ) 1 q - 3S-21)
Email: C'oc T e, i..-z4 e?A.A.t(...o vAs i- ,/O. e,-prk Alt-,co .iv,
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Ton Blitittr.9 A,COOP Fr.tfrgr Arnnt PrinCtellp Strut tl;rr.Rp-ri,,,-pgl MaiTh"MS
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PROJECTAI.ELE) MATION:
TYPE: Commercial X Residential
WORK CLASS:
Single-Family › Two-Family Multi-Farnily(*of
Townhouse Business Office Retail Hotel/Motel
industrialMtarehouse Garage(*of cars ) Other(describe )
STRUCTURE SQUARE FOOTAGE: GARAGE SQUARE FOOTAGE:
a10 cE 1 0 isTfloor: 23 I
24d floor: rd floor:
3rd floor:
Total square feet: 9-3
Basement(habitable space): S S-
Total square feet: iq
ADDITIONAL PROJECT INFORMATION:
1.. Estimated Cost of Construction:$ I /71 0 0 0
2. Proposed use of the building: R.ES IDE-wit/AL ( VLL
. if Commerdal or industrial,indicate the name of the business:
4. Source of Heat(circle one): IMP 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 plain:
6. Are there any easements on the property? YES f(Di.
7. SITE INFORMATION;
a.What is the dimensions or acreage of the parcel? toz-447-44-424alar
b. is this a corner lot? YES 411Dow
c.Will the grade be changed as a res he construction? itaii NO
d.What is the water source? •!mu PRIVATE WELL
e.Is the parcel on SEWER or a PRIVATE SEPTIC system? SFr tc-
Cce- FaiRc fi et. C-9-4b (r- FLA e4
VoCe,ul idin2&CM nfarCPITLAnt Prineinto Stntrilird Rotriegri Marrh 7nig
DECK'': .. llO :
I. lacknowledge that no construction shall.commence prior to issuance of a valid milding
perm 'and work will be completed within a 12 month period.
2.. If the work is not completed by the 1year expiration date the permit may be renewed,
subject to fees and department approval.
3. l certify that the application, plans and supporting materials are a t rde 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 locW 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 litve are required to provide an as,-buff survey by a licensed land surveyor of
all'newly constructed facilities prior to issuance ofa certificate of occupancy.
1 have read and agree to the above:
PRINT NAME: d S l PIA t 1
r
SIGNATURE
DATE: 1
•
To:Bu1l4ina&Code Enforcement Prinrinia'tnui„ro Ravicarl 26i.rrh 7r/lR
-
''''is- , 44 SEPTIC, DISPOSAL PERMIT APPLICA l I ON
14 e vPayRoad.Qu-::-_,ri Jury, • •t[4 1
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TEE, Map ibis. 3E1 t'g-- E-2./ •...f': ...._'.J_!..... . .. .
6 -•g-- t -21. du. 1-12_ i ,
Pr eject L,oc3t o f _.
11 Primary Owner(s) )-p i 11 E;--L-S ? i;. 00 c Le A A)
C
It i ailing Address .
,i i riA toi.ev i A 1 i�4 i 1)€ l�}Z C t,t,-,,, c,,P,.,� .t- .(2 ci `i
iI Phone & Email `.CS-if t --0 '5 s i )%7' 3.c,-z< ... ... . c:T.ii. iL�-S i LUIS I 1 e:r-felfi l_,OW.i
•
!1 installer/Builder
h+lailing Address
it Phone & Email
Engineer ...---..
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t ;� tL. pp
Bailing AddrreSs -
l ,�-i C_;1 nr%r g► •�i.A-e'e t S 3�t.g.• .b.)`.t 1 �% 1
Phone & Email .(S I j)19(v' 1 5‘ C4:N re 30 @ YA 00,,t O rn'+
Contact Person for Building&Code c(=aryl to i 6�An sc- .t 73G. i...`'A(4 .h Q 0: eS 3 -) t`i d 71133
S`i.�'� #`'ice: 3,��.�'
1 RESIDENCE NFORMAT1ON: -_. _ .
I
• ` ear Built o"bedrooms _ I Garoa e Grander Ye•s
s
1 X gallons per 6ecirPom. tot-'daily flo k =3
'980 or older I install-eV (circle onej
_.__. • r Hpit Tub
t .stall- (circle
,_..._..,�......._... installed? one)
2-Present; �� ( t b.. 33
• PARCEL NFORMATION: •
- Topography 5 ,C` pLA 41 Plat Rollin Steep Slope `-`o Slope
Soil Nature S• r�cl ,._Loam Clay Other
1 Groundwater 1 At whet depth? '
Bedrockiirriper�,i bus materiai At what death? tJO •
if'Dom esticW ate r SuppK/ • X Municipal _ Well{if weli.water supply from any seootic s stern absorption' Is it
Percolation Test : Rate. 1^5' per minute per inch{test to be completed.by licensed engneertarci tecty
3 .PRO •
POSED SYSTEM FOR NEW CONS'RUCTION:
1 Tank size "/._:-- 0 0 gallons:_{rnin,size 1000 gallons,add 250 ga lions for each garbage cylinder or spalhat tub
1System ! Absoration field wrth#2 stone Total length 5.—6 - ft..EachTrench y`r tJ It, w
•
1; • • --1 Seepage Pitwitlt#$stone How Many:_ . ,Size: _ _ _
Aiterrative System tied or other type: I
11. 1 i-lpldingT.ank Systems 'requiredTotal capacity? -tank size :# of tanks
10TES:1,A1arm'system&assaciatCdelectrica Iwo tkt ustbeinspectedbyaTownapprovedelectricalinspection .
agency.We Will no longer allow aystems to be covered until such time as en as-built plan'e'received and approved.
The installed system must match the septic layout oh file-no exceptions.
Deblaration:Any perms oreppfpvai gra.nied which is based upon or is granted in reliance upon any Material
representation o:•failure to make a material fact or circumstance known by or On behalf of an applicant.shalt be 4c id,t
'have read the regulztions'eendagreeto abide bythesear-tciail requirements ofthe Town ofQ teefsbliryF-r...r`an.itary Se`e,,age
.Disposal Ord inane.
PRINT H.AME: '3 O C ER 14 __LSO-C.( DATE- 4 I a ----