applications Office use:Only
PRINCIPLE`NCIPLE STF UCTURE PERMVirr Permit n: Q.0 A D � -o t 3
•
APPLICATION Permit Fee:$ 1l oc0
*Rec. Fee:$
742 Bay Road,Queensbury, NV 'P804
P: 518-761-8256 www .queen.•bury.net Invoice#:
Project Location: 123 We4 N w tps 12e)
Tax W Y p #: ibt • - 1 - 1Q�j Subdivision Name:
TOWN BD.RESOLU T!ON 86-2013:$850 recreation fee for new dwelling units: single family, duplexes/two-family,
multiplefamily, apartments,condominiums, townheuses,and/or manufactured w modular homes, but not mobile
homes. This is in addition to the permit fee(s).
CONTACT INFil!•:MATION: .
o Applicant: A
ii
Name(s):
Mailing Address, C/S/Z: ;�C� �����atio A - L X,d V 12
Cell Ph.: ( 5( ) --52 l - gi2.Jf9 / Land Line: _( ) /mil
Email: 0,11 n s
Primry a 0wner(��P
Name(s): ( 3ok- 'Ou_p-
Mailing Address, C/S/Z: 1 /'' 1g 4
Cell Ph.: _(S l ) -Ai -1 - 9 2c t j Land Line: ( )
Email: @ V\rt.S --- 'G ti4 hc,o, .
/
o Contractorr(s):
Name(s):
Mailing Address, C/S/Z:
Cell Ph.: ( ) Land L19 (� )n 11e7 I° .
LG Email: .Y e��
• Architect(s)/Engnieerr(a)o JUL 16 2018
Name(s): • 0 e:uruMM CF I IFFNRRURY iA
Mailing Address, C/S/Z: BU1L0NE
Cell Ph.: _( ) Land Line: _(, )
Email:
Contact Person for Building & Code Compliance: .- I t e_ottr-
Cell Ph.: _( 6li ) - zcfl Land Line: _( )
Email: Cf(1 yes ` +Cam? i�uN.� . v:
PROJECT_JNlrORMMMATION
TYPE: Commercial *Residential
WORK CLASS:
a! Ingle-Famiiy Two-Family Multi-Farnily(#of • )
Townhouse Business Office Retail Hotel/Motel
Industrial/Warehouse Garage(#ofcars ) Other(describe
VI floor: 1 . LA.C5 1ST floor:
2' floor: 2nd floor:
3RI floor: Total square feet:
Basement(habitable space):
•
Total square feet: I Igo
•
•
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $
2. Proposed use of the building: Aag-55crii -�
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 App i ai&Chimney Application, one per appliance)
5. Are there any structures not shown on the plot plan?
YES NOExplain:
6. Are there any easements on the property? YES N® i
7. SITE INFORMATION:
a. What is the dimensions or acreage of the parcel? _`"l
b. Is this a corner lot? YES NO
c. Will the grade be changed as a res tit .construction? YES NO
d. What is the water source? P _BLIC - PRIVATE • WELL
e. Is the parcel on SEWER or RIVA SEPTIt .system?
DECLARATION:
l aok.nowiedge that no construction shall ::ommen.:e prior to issuance -„f'a ✓otlid b i lclii
T.erni - and work will be completed within a 12 month period.
2. If the work le not completed by the `!year e;:piration date the permit may be renewed,
• subject to fees and department ent approval.
3. I certify that the application, plans and support ino materials era a t rue and complete statement
and/or description of the work proposed, that ail 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 pier to occupying the facilities proposed I, or my agents, will obtain a
certificate of occupancy.
5. I understand that Uwe are required to provide an as-built survey by a licensed land surveyor of
all newly constructed facilities priorto issuance of a certificate of occupancy.
•
have read and agree to the above:
PRINT NAME: OAVA,Se\-00\c—
'SIGNATURE: DATE: ,__„ p��.1_
•
•
•
_ _ _ _ _ - -
, - Tire? ; SEPTIC DISPOSAL PERMITS APPUCATI ON Of }se Oi,I
:- 742 Bay Road,Queensbufy,NY 12804 �m_.-_,___ _.._.,.,....._.
4:518-761-8256 :.f'.. . ........:r,t .. a::: ;'ermu.:=;- - \21-• be)
Tax Map[D s;. Permit Fee:$ •IriiiCair.,.f:-s':
Pr*c:N,®c*ion: Septic Variance? -,Y?z4 , N o
Primary Owner(s) ,„„C.Y.11, -____ I-sf
Mailing Address
Phone& Email
I tf �� -
a � � cc. V pim .__
Installer/Builder
Mailing Address
Phone & Email w� is J —5 2_4
Engineer
Mailing Address
Phone& Email _ .- — --- - --- -- - —
Contact Person for Building&Code conripfl ialrle ie: 1 - - Pf,w� ; L5`8.)-3 -52-5'3
RESIDENCE NFORMATION: _ __ _ _
Year Built # of bedrooms X gallons per bedroom = totaldaily flow Garbage Grinder_ _.. _.__ Yes No
1980 or older Installed? {circle one)
1951-1991 .
Spa.or Hot Tub Yes No
• Installed? {circle one)
rase n
PARCEL, INFORMATION:
Topography Flat Rolling teep Sloe- %Slope
Soil Nature (,?,Sand _Loam Clay Other
Groundwater At what depth? 1,1
Bedrock/Impervious mate rial -At : hat depth?
Domestic Water Supply ;,_ Municipal _Well{if well,wate r supply from any septic system absorption is ft.)
Percolation Test Rate: per minute per inch{test to be completed by licensed enieer/arcl-tect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size 600 gallons{min.size 1,000 gallons,add 250 gallons for each garbage cylinder or spa/hot tub
Absorption field with#2 stone Total length ft.;EachTrench ft.
MIN Seepage Pit with#3 stone How many: . •Size:
III Alternative System Bed or other type:
HoldingTank System Total required capacity?. •tank size ;# of tanks
NOTES:1.Alarm system&associated electrica Iwo rkmust be inspected bya 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 of the Town of Queensbury Sanitary Sewage
Disposal Ordinance.
ii
f----)
PRINT NAME: UN--li,SkarCli�i ��-; .. DATE: 1( Gl¢
effj .._____. , 4
SIGNATURE: DATE: l/ II' v"