applications Office Use Only
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PRINCIPLE STRUCTURE PERMIT Permit t-t:
APPLICATION Permit Fee:$
*Rec. Fee: $ e) (3
742 Bay Road Queensbury, NV '2804
P 518-761-8256 •:.z • I Invoice#:
Project Location: 23 A AIM cfroke a/0(re- gb
Tax Map #: 30C.8 - 1-2/,6 Z- ft Subdivision Name: NA-P-v-T
TOWN BD RESOLUTION 86-2013 S850 recreation fee for new dwelling un zs single family, dup s two-family,
multiple family 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): 0 TH ILLS CRS (-3-0E Lev,c-t
Mailing Address, C/S/Z: 9 iyibutJTArtuciocr bRive 1.JY ig-ro
Cell Ph.: 1 ( ) -7"1 - 33 1 (St T ) S-24 (Ce-4.4.9
Email: Forititi- 5%),1 L-DERs N g C—rn co rtiN
• Primary Owner(s):
Name(s): SA M6 As A PPLI c ANT
Mailing Address, C/S/Z:
Cell Ph.: ( Land Line: (
Email:
• Contractor(s): JUN 1 2 2018
Name(s): S Am PiS PpLt No- i
Mailing Address, CIS/Z: TOWN C.,F, JUEY
Cell Ph.: ( ' Land Line: ( -----
Email:
' • Architect(s)/Engineer(s): AP BAD (3f G-Let.is FALL-s .
Name(s): ji i20
,
Mailing Address, C/S/Z:
Cell Ph.: ( Land Line: I ( ? ) o2kg
Email: - e-p NALL
Contact Person for Building & Code Compliance: joE Lctk
Cl
Cell Ph.: 1 (T(l ) 1(11- 1933
Email: Foci'kk 8(A. Lo et2,swie / t-, co INA
Ton RffildingP COCIP Filf0fTPMPrIt Prinrinlp Strurtilre Reviced Mardi?ma
PROJECT INFORMATION:
TYPE: Commercial X Residential
WORK CLASS:
_Single-Family )c Two-Family Multi-Family(*of )
Townhouse Business Office Retail Hotel/Motel
_ _Industrialnarehouse Garage(#ofcars ) Other(describe )
STRUCTURE SQUARE FOOTAGE: GARAGE SQUARE FOOTAGE:
1sTfloor: 9 I 0 15T floor: 23 I
2nd floor: 2nd floor:_
3rd floor:
Total square feet: 23 I
Basement(habitable space): S. S
Total square feet: 1 -!(0 S
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$ I S-1 0 0 0
2. Proposed use of the building: 4 'CS I i ENT/AL
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 Appliances&Chimney Application,one per appliance)
S. Are there any structures not shown on the plot plan? YES NO ` plain:
6. Are there any easements on the property? YES NO
7. SITE INFORMATION:
a.What is the dimensions or acreage of the parcel? Os ÷ qS
b. is this a corner lot? YES IlLog
c. Will the grade be changed as a res the construction? 4116 NO
d.What is the water source? 'LIBLI• PRIVATE WELL
e. Is the parcel on SEWER or a PRIVATE SEPTIC system? SEPT I(-
SEE A- riv._ C--tekbING- FLAN
Ton Bulldin¢&code Enforcement Prinrinte Stnurtrire Raviceri Marrh fl 1R
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 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. 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 provide 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: 3-oseP L-E1A-
SIGNATURE DATE:
•
Prinrinla Ctrurtkira RavicAti M.-urh 7n152
ToQ Building&Cade Enforcement
~
`
~^-. . ._ DISPOSAL._ PERMIT APPLICATION
" L.",`..`'..
Project Location:
Li c-
-_—"Address
MailingAddress
mail
Mailing Address
Phone& Ewalt
Contact Peraonfor Building 8~Code C,- pt ie* 30 e7 L6w' F�1,t-i c>nne--: }� � | - /43�
\ -�9 6~3�2 0
RESIDENCE NFORM/�lDy� _'-__�
Year Built of bedrooms X gallons bedroom � Garbage ' Ycu �Nu�
_-_'_'-'�--'- -- �~' - ` �^~^` � ��
Installed?73D8oro\der / v/vu^/
- -' - ---''- -------'--'-`------'-------'-^ ' —~'-- -- -'~---- Spaor Hot Tub Yes UVd )
Installed? {circle }
1992-Pnaoeny7~~~-------~~~~- � / ---- -' --7 ' -- -- - ' --
/}
PARCEL �FO�MATION:
opography
iJ Flat Rolling Steep Slope %Slope
~~~---~—~--~-~--^--
Groundwater At what
^-------~------------------------ ------~----`-'----'-----'---------~-----'-''- ---'
estic Water SuppV IV
V Municipal _Welt�if well,water supply from any septic system absorption is_ft.)
I-P,ercolation Test Rate per minute per inch Jtestto be completed by licensed engineedarc�tect)
ED SYSTEM FOR
Tank size 1 0 gallons{min.size 1000 gallons,add 250 ga(Ionsfor each garbage cylinder or Spa/hot tub
System Absorption field with#2 stone Total length i�, ft.,,EachTrench
Seepage Pit with#3 stone How many: Size:
Alternative System Bed or other type;
HoldingTank System Total required capacity? -tank size 1 of tanKs
NOTES:TA[arm system&associated efectrica Iwo rk rnust be inspected bya Town appi-oved electrical inspection �
agency;2.VVe will no longer allow systems to becovered untlisuch time as an as-bUiltplan is received andapproved.
The installed system must match the septic layout on file-no exceptions.
DeclarationAny permit or approval granted which is based upon or is gra nted 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.1 .
have read the regulations and agree to abide bythese and all requirements of theTown of Queen5bUry Sanitary Sewage
Disposal Ordinance.
PRINT NAME: ~�D�<�� A / ��<���/ __ DATE
G|GNATUR � _ DATE:
�� � �
•
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:518-745-4466 David Duell
Deputy Highway Superintendent
Home:518-745-0938
DRIVEWAY PERMIT
Date:
Applicant Name: Fo 0 j-k tL t.A-4 LE) (2-3 (70 Le-LA C-
Telephone No.: I 31j /(, c)g)-7`;6,--35-2,0
Address to be inspected: 2-3 A Et eNo r•• •
Return Address: rrko,to TA //v SAD& De-
Ove-ew S LA(4%-/ is14 ( 2A-6
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 building&Code Enforcement Principal Structure Application Revised February 2D17