applications PRINCIPAL STRUCTURE PPLICATION Office Use Only
DATE
Received
Tax Map ID
TAX MAP ID Permit No. P-C-" �—,e5- ?.z\l-
Permit Fee Ayo5
ZONING Rec Fee rg� - 224--)r
Site Plan#
HISTORIC SITE Yes /No Subdivision #
SUBwyis10N NAME74116-S)-A- Lot# 6o-ravi-e104tgk4l Rae PtWe
TOWN BD.RESOLUTION 86-2013: $850 RECREATION FEE FOR NEW DWELLING UNITS,INCLUDING SINGLE FAMILY DWELLINGS,DUPLEXE
OR TWO FAMILY DWELLINGS, MULTIPLE FAMILY DWELLINGS, APARTMENTS, CONDOMINIUMS, TOWNHOUSES, AND/OR MANUFACTURED i
MODULAR HOMES,BUT NOT MOBILE HOMES. THIS IS IN ADDITION TO THE PERMIT FEE.
APPLICANT /Ca[.}/7?e--
ADDRESS � ,V _ ADDRESS
PHONE/E-MAIL J l l r� PHONE/E-MAIL
CONTRACTOR COST OF CONSTRUCTION(ESTIMATED): $
ADDRESS: BUILDING ADDRESS:
PHONE/E-MAIL
51$
CONTACT PERSON FOR BUILDING&CODES COMPLIANCE: PHONE 5bl- 6 33
TYPE OF CONSTRUCTION
Check all that apply Please indicate measurements as required below
New Addition Alteration 1s1floor sq.ft. 2nd floor sq.ft. Total sq.ft. Height
Single Family / -,
Two-Family
Multi-Family
(#of units )
Townhouse
Business Office
Retail - Mercantile
Factory- Industrial
Attached Garage
(#ofd)
Other
Town of Queensbury Building&Codes Principal Structure Application July 2014
If commercial or industrial indicate name of business
Proposed use of building or addition Of/6 Li
Source of heat (circle one) Ga Oil Propane Solar Other
Fireplace: complete a separate application for Fuel Burning Appliances &
Chimneys
Are there structures not shown on plot plan?
Are there easements on the property? / R
Site Information
a. Dimensions or acreage of lot
b. Is this a corner lot? ^/R
c. Will the grade be changed as a result of construction Yes No
d. Public water or Private well '
e. Sewer or Private Septic System
Value of all work to be performed (labor or materials) $ (�
DECLARATION-
1.
ECLARATION;1. I acknowledge no construction shall be commenced prior to issuance of a valid permit and will be complete
within a 12 month period.
2. If work is not complete by the 1 year expiration date the permit may be renewed,subject to fees and departmer
approval.
3. 1 certify that the application, plans and supporting materials are a true and complete statement/ description c
the work proposed,that all work will be performed in accordance with the NY State Building Codes, local buildin
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 occupancl
5. 1 also understand that I /we are required to provide an as-built survey by a licensed land surveyor of all newt
constructed facilities prior to issuance of a certificate of occupyy cy.
I have read and agree to the above: PRINT NAME: / ' /�2 C___ DATE
SIGNATURE: DATE
FOR OFFICE USE ONLY
Operating Permit Issued: Yes No
Occupancy Type
Construction Classification
Assembly Occupancy Limit
Special Conditions
Town of Queensbury Building&Codes Principal Structure Application July 2014
Fuel Burning Appliance & Chimney Application Office Use Only
` Received
DATE: 9�y Tax Map ID
TAX MAP ID: Permit No.
Permit Fee
ZONE:
OWNERzf PHONE/E-MAIL
ADDRESS
INSTALLER/ PHONE/E-MAIL
BUILDER 9,k,��o 0
CONTACT PERSON FOR BUILDING&CODE COMPLIANCE:
PHONE/E-MAIL rk :�ZI'6-3:3/ BUILDING ADDRESS Wf d-
ROOM OF INSTALL: C�,�'�t r�s. PLANNED INSTALL DATE: � f'�)
FUEL BURNING APPLIANCE INFORMATION WOOD COAL PELLET GAS OIL NOTE: ROUGH-IN&
STOVE FINAL INSPECTION ARE
FIREPLACE INSERT REQUIRED.
FIREPLACE,FACTORY BUILT* NOTE:
MANUFACTURER'S
FIREPLACE,MASONRY
INSTALLATION MANUAL
FURNACE(GARAGE ONLY) MUST BE AVAILABLE AT
TIME OF INSPECTION
*If factory built provide manufacturer name: oL. ; Model#: ?:
Listed by: Number:
CHIMNEY INFORMATION
Masonry** (check one) BLOCK BRICK STONE
Flue TIE STEEL Size in inches
Material DOUBLE WALL TRIPLE WALL INSULATED
** If non-masonry provide manufacturer name: ;Model#:
DECLARATION: Construction/installation must conform to NYS Fire Prevention & Building Code and/or
manufacturer requirements. The applicant or owner agrees to comply with all applicable laws, ordinances,
regulations,and all conditions that are part of these requirements and also will allow inspector's to enter premises
to perform required inspections.
I HAVE READ AND AGREE TO THE ABOVE:
PRINT NAME: DATE: I
SIGNATURE: DATE:
Town of Queensbury Building&Codes Principal Structure Application Revised September 2014
SEPTIC DISPOSAL PERMIT Office Use Only
QASE 7 f 7 Received
Tax Map ID
TAX MAP ID Permit No.
Permit Fee
LOCATIONOFINSTALLATION �U w/fit L4 / Approvals:
APPLICANT
�[ /gGl �J C� PHONE/E-MAIL
ADDRESS
INSTALLER/BUILDER: �' � PHONEI E--MAIL F �
ADDRESS:
OWNER PHONE/E--MAIL
Address
CONTACT PERSON FOR BUILDING&CODES COMPLIANCE: G�LIL/ — 1 PHONE11 / :�5 �
RESIDENCE INFORMATION
Year Built #of bedrooms X Gallons per bedroom =Total Daily Flow
1980 or older Garbage grinder installed Y
1981-1991 Spa or Hot Tub installed Y N
1992-Present
PARCEL INFORMATION
Topography Flat rolling Steep slope %slope
Soil Nature Sand Loam Clay Other
Groundwater At what depth?
Bedrock/Impervious Material At what depth? 4414
Domestic Water Supply Municipal Well(if well,water supply from any septic system absorption is ft.)
Percolation Test Rate: per minute per inch(test to be completed by licensed engineering/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION
Tank Size 4my gallons(minimum size 1,000 gallons,add 250 gallons to size for each garbage grinder or spa or hot tub)
System Type Absorption field with#2 stone Total length ft.;Each trench x
Seepage Pit with#3 stone How many: ;size
Alternative System Bed or other type?
Holding Tank System Total required capacity? Tank size #of tanks
Notes: 1)Alarm system&associated electrical work must be inspected by a Town approved electrical inspection agency;2)We will no long,
allow systems to be covered until such time as an As-Built plan is received&approved. The installed system must match the septic syste
layout on file—no exceptions.
DECLARATION: Any permit or approval granted which is based upon or is granted in reliance upon any material representation 4
failure to make a material fact or circumstance know by or on behalf of an applicant,shall be void. I have read the regulations ar
agree to abide by theawaod all r9quirements of the Town of Queensbury Sanitary Sewage Disposal Ordinance.
Print Name: Date:
Signature: Date: 71 7
Town of Queensbury Building&Codes Principal Structure Application July 2014
T,-,-,Ajn of Queerisbury Thomas R. Van Ness
Highway Department Highway Superintendant
742 Bay Road, Queensbury, NPI( 1280-1, Horne: (518) -1745-0929
Phone: (518) 761-821 1
Fw4: (618)7'45-4-466 David Duell
Deputy Highway Superinie�derii
Home: (518) 745-0938
DRIVEWAY PERMIT
Date:
Applicant Name:
Telephone No.:
Address to Be inspected: ilk
�50,
Return Address: /L 1
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 O Rejected
Date:
Thomas R. Van Ness, Highway Superintendent David Duell, Deputy Highway Superintendent
Town of Queensbury Building&Codes Principal Structure Application July 2014