application s ,
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Office Use Ont:
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PRINCIPLE STRUCTURE PERMIT ,1 0 Ar-i-
t
- Permit Fee:5 6iA,50
_ APPLICATION _
'Rec, Fee:S
742 Bay Road C.,'Lleensbury. NV V.3C4
P 518-751-8256 invoice 4:_ 6511--
1 _
4q-31,(Ydr-L,2--karsj
Project Location: il _tt 238 grriot..e- goG-e- gp
7.
Tax Map #:1M11111.111."-- 4 30g-.' - 1- '4(Subdivision Name B(A124,1T g_106--C
TOWN BD RESOLUTION 86- 013 S850 recreation fee for new dwelling un ; I:•:.1 . dup two-family
muitiplefamily i.ii.Lii:ir.:-t; :... .. . .ii5 ,.. 11 . .2 -7 and o. manufactured ,. mo T.:1r homes . •,.. not r'L
homes This is in addition to the permit.feets).
CONTACT INFORMATION:
• Applicant:
Name(s): cr o T H I t-c. 3 I.,.I(...1) E-g,S E-St,E LE ( )
Mailing Address, CISIZ: 3 1r 0 Li.r.)TR WC i 0 (7: bR l vE"-- atA0.-7i-)5.13LLIZI ts-)V /.4-e-C 1
Cell Ph.: 1 ( s-t i: ) -Vi 1 - li . 3 Land-Li-Re: t (S--IF ) 52.c. (CcFci....)
Email: Icc Tt-uo_sE.At L-DERS N"i 0 C-rn 4 i I- C-C IV\
O Primary Owner(s):
;-;_,.
Name(s): stvne Fls A ppi_i.c AN-; 1 i L-1...1! ,_.:,/
Mailing Address. CiStl:
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, 1 itItt1-2 '
Cell Ph.: ( 1
; uI- 20t8 il
.._, Land Line: ( fP
---; -- ---,--:-_ 7,-,..---i 'l)/
Email:
• Contractor(s):
Name(s): S A m e- 6S APPLi (..IN-r
Mailing Address. C/S/Z:
Cell Ph.: ( ) Land Line: ( ) _
_
Email: .
• Architect(s)./Enqineer(s): E-i RAP OAL.-/- 13(1 Dil.. Av6 Gtews FALLS N'-i
Name(s): _ _ __ _, - •-• „ ,...;. 12-i-0 1
Mailing Address, C/S/Z; ,-:----;-----=--'::---=-7----:-''f—.-----L.: --.--,-----=,-,r, ---.. ,-A--- --------'--7:-.- I _
Cell Ph.: __( __) Land Line:
...
Email: , --,......,::..irc- f- ---tr l l't ' - C-•-• P ti AL-1--@JJ y .c..tle_, Kg,...... co fv•\,
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Contact Person for Building & Code Compliance: ) 'c• 1--"`c-1 .,,
—
Cell Ph.: 1 (S--IV ,....), 141 I- (9 3 kerftd Line ) -1 cf - 3S-2-cC.:674-1-I
Email:. Fut-- IL:Y.4 f3t,i.i LAG t2.. `1 @ 6-in (..x. ,-,\ _ _ --
a. Re•est,(1?,1)
Tr('ht.:0 N-,e,.e Mr.i•Ifnr,h.ft,41
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PROJECT INFOF RATION,
TYPE: Commercial X Residential
WORK CLASS:
Single-Family `1 Two-Family Multi-Family(#of ) •
Townhouse Business Office Retail _ HotellMotei
_Industrial/Warehouse Garage(#of cars ) Other(describe )
STRUCTURE SQUARE FOOTAGE: GARAGE SQUARE FOOTAGE:
i.floor: 9 I 0 1st floor: 23 !
2"d floor: 2n6 floor:
3rd floor: 13
Total square feet:
Basement(habitable space): S. S 6--
Total square feet: (`l((S
ADDITIONAL.PROJECT INFORMATION:
1. Estimated Cost of Construction:$ 1-1 5-i 0 0 t
2. Proposed use of the building: ll?a S i tb i;t 1 t AL 14,0 -f R m l L Y
3. If Commercial or Industrial,indicate the name of the business:
4. Source of Heat(circle one): OP 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 e, plain:
6. Are there any easements on the property? YES NO
7. SITE INFORMATION:
a.What is the dimensions or acreage of the parcel? 0•f 7 S- + 6.Sr.
b.is this a corner lot? YES Co
c.Will the grade be changed as a res r •_ the construction? ei NO
d.What is the water source? CT* PRIVATE WELL
e. Is the parcel on SEWER or a PRIVATE SEPTIC system? SE-PT I
%SEE- A-1'11g i CA R.-AWN G- ELAN
Tntt Bulklina&(entla Enfnrcamant PrinrinM K4nrrnIre Ravicomi March 7f11R ,
DECLARATION:
I. I acknowledge that no construction shall commence prior to issuance of a valid ouilding
perm and work will be completed within a 12 month period.
2_ If the work is not completed by the lyear 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. 1 acknowledge that prior to occupying the facilities proposed I,or my agents, will obtain a
certificate of occupancy.
5. I understand that lMre are required to provide an as-built survey by a licensed land surveyor of
issuanceoff u anc
all newly constructed facilities prior to acert►ficate o occ p y.
•
I have read and agree to the above:
PRINT NAME: 3-OS iy P l-t LE '
SIGNATUREC DATE: _ G t it/ 18
•
Toa BuHdtno&Code Enforcement Prsnrink.ctnvtura RovfeAst Marrh sntR
•
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SEPTIC DISPOSAL PERMIT APPLICATION
ON
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•,......;:„../ 7 Es,ic :: Cu n bury A•.'• 4,-1 .
P:Al N li, 4'.0 P."-tr,11 _ _
Ta M•.p ID,it- 30E-,F -- i-2/ .4,/
30E-4 - I -21, 6 z.. I _
proictLoc_ation: I - - __
• _
Pre-riani Owner(s) F.0 C•-i-I-1 I 1-z-S IlL•'•1 L.I),ei:5., 1._(„-c. C.SQ;- LE Li c't)
Mng Addresi,e 1).\(‘-'-i••-TiA ts;'il toe -6'it CII,E- :, ;--•rt-t 1---' /286 i
...
Phone & Email (5-1.0-ri l -1(13 5 / Cr[019 - 3S-2.0• reCTel i t-t-S f3tA i Lu-121,-)-1 6)6:-IlmiL.6"‘An
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Installer/Builder
I . Some-
Mailing Address
i - _. ._ .. _ - -•- •
Phone & Email
Engineer
. -It rY\ e_e_tu T er P.„ _PS. • •
Mailing ;Address 1Cti 14R V:IL A N (Z.! CztA,-60r4S8 t-i p.:i i,_ii 12..g 0 1
— _ ______
Phone & Email (S-.I it) 1 ci(,--.2-S-.1 S' TtL.Gr-riC3b @ YA tic o. r''''
Contact Person for Building&Code ,c)rr-1 pi la.rt : LE tA.<-) F>h ce.rrit : (:'S
RESIDENCE NFORMATION _
Year Built z--- of bedrooms I Xallons per bedroom ti:- zotalcaity floir,- . Garbage Grinder I-Yes Nci '
1950 or older . l . ,
.. • Installed', {circle dee, '
! 1951-1991 •. . 1 Spa or Hot Tub ! Yes Nu,
. . '092-PresenF 3 i Installed% {circle one,
1 0 •
i
PARCEL NFORMATION:
Topography Sc_C- PIA Ai Flat Rollinc Steep Slope Slope
. _
Soil Nature ..__Sand _Loam Clay Other
Groundwater At what depth? _ _ — •
Bedrock:Impervious material Al.what depth? iu 0 .
Domestic Water Supply D( Municipal _ Well{if well .rater supply from any septic system absorption is l'i
Percolation Test Rate J -S per minute per inch{test to be completed by licensed engneer.,arcrtecti
PROPOSED SYSTEM FOR NEW CONSTRUCTION
1 Tank size /0 C) () gallons{min.size 1000 gallons add 250 gallons for each garbage cylinder or spa'hot tub
i Syste-n , ,l Absorption field with#2 stone Total length s--b IL:Each T rend') / S-t.) 11
--).e_epage Pit vvith#2,stone .... I-1,ow many _ Size
11 ! Aternative System Bed or otner type
ti --li:-- --71
_ -
; HoldingTank System - ' - Total required capac,tp tank size of lans.
NOTES: 1 A lam system&associaiect electr ica I work must be inspected by a Town approved elect%'cal inspe;tion
agency.2 We will no longer allow siverns to he coved until.wch time as an as•-built plan s received and approved .
The installed system Must match the septic layout on file-no exceptions
Declaration 1.-ns4 perint or approval granted‘11 Nth is based iipon or IS gta nted in i eltance upt.)tt any'11.-ite;sal
representation oi failure to make a material fact of.cireko•nrio,ance Icoov.'n by oi on behalf of an epplic,ant $1,..11 Le%c.,,,,,f
have read th replations tind agree to abide by thei!,:4.•and all require-news of the 1 own of 01.ieellsbu;y Senitxy Sewage
Disposal Ordinance
.
PRINT NAVE :3 0 S E p a Le-a.(---1 DATE._
.„._ -- -
SIGNATLIR,_.q - 71--A..:
_ DATE
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s f '
Town of Queensbury Thomas R.Van Ness
Highway Department Highway Superintendent
742 Bay Road,Queensbury, NY 12804 Home:518-745-0929
Phone:518-761-8211
Fax:518-745-4456 David Duell
Deputy Highway Superintendent
Home:518-745-0938
DRIVEWAY PERMIT
Date:Applicant Name: Foe ;H i L-(- &It 6' Le'u c-()
Telephone No.: -(5 l0"2' t- i S 3.5 1( 1 18) 1 t 6-
Address to be Inspected: 23 F1 4 $ S n\4 irg- 4-(0G-t' 1DiS-
Return Address: c(' 1'r1C k N T A 1 t 5 iD E
l tve-Eti C 6,(CN tI.{ I z.r
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: ( ) Preliminary approval
NEED ( } Slight Swale
( ) Deep Swale
( ) 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 approval permit for a final approval.
STEP 2: ( ) Final Approval ( ) Rejected
Date:
Thomas R.Van Ness,Highway Superintendent David Duell,Deputy Highway Superintendent
Town of Queensbury Bulling&Code Enforcement Principal Structure Application Revised February 2027