applications . ' Office Use Only
PRINCIPLE STRUCTURE PERMIT
) Permit#:
APPLICATION Permit Fee:$ lb1.2-0
- :
*Rec. Fee:$ bcDo
742 Bay Road,Queensbury, NV 12804 .
P: 518-761-8256 .-.....:. 'T+P ' t- ', 1. ' Invoice#: 0 Vil
Project Location: Il/cc 4. h - 3 ,
Tax Map #: Subdivision Name:
TOWN BE/RESOLUTION 86-2013:$850 recreation fee for new dwelling units. single family, duplexes/two-family,
multiplefamily, apartments,condominiums townhouses,and'or manufactured & modular homes, but not mobile
homes, This is in addition to the permit fee(s).
CONTACT INFORMATION:
• Applicant:
Name(s): dszme no/ail .4-,/t_ -
Mailing Address, C/S/Z: /ref-Ve f /4-01- 4...At/Id ,ti-/. /4F--zr"
Cell Ph.: _,(rig) 3‘/-gq Z--- Land Line: (4-1 ) 9ed- 17767
Email: ft7:4;e:61,1e.„ ,p g ive,-/
• Primary Owner(s):
Name(s):
Mailing Address, C/S/Z: - c0/14 1pl
Cell Ph.: ( ) Land Line: ( ,
) / ' V JO -h ---, 4,, /,-.;,'3 7
Email: ,,, )
i :'bkim,',1-,,,, I/ati) V/
- -9
Rii?e-----,, /g/
• Contractor(s):
L;06;1:All,-
Name(s):
Mailing Address, C/S/Z: (..
Cell Ph.: ( ) Land Line: ( )
Email:
• Architect(s)/Enclineer(?):
Name(s): 14 f eil 4/2Vitie(e/ff' -
Mailing Address, C/S/Z: e..64 (0"/64,/ dir- . aka 7'.--,d/r 4/
Cell Ph.: ( ) Land Line: (. /A:1 9).-- 97,24I
Email:
Contact Person for Building & Code Compliance: 7;1;gfre- iiii S7/177,11e---'
Cell Ph.: _(,r_lir) 7er. 7977 Land Line: ( )
Email: ,
To0 Building Rr Code Enforcement Principle Structure RevisPd March 201R
^j
PROJECT INFORMATION:
TYPE: Commercial Residential
WOR LASS:
Single-Family Two-Family Multi-Family(#of )
Townhouse Business Office Retail Hotel/Motel
Industrial/Warehouse Garage(#ofcars ) Other(describe )
STRUCTURE SQUARE FOOTAGE: GARAGE SQUARE FOOTAGE:
1sT floor: = 1// lsr floor: [�
2nd floor: =`. - 9T6 2nd floor:
3rd floor Total square feet: WO
Basement(habitable space): 'r-�
Total square feet: J'-' 1�2 f
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$ 'e� CVO
2. Proposed use of the building: $/-iy//
3. If Commercial or Industrial, indicate the name of the business:
4. Source of Heat(circle one): Gas Oil Propane Solar Other:
(Fireplaces need a separate Burning Appliances&Chimney Application,one per appliance)
5. Are there any structures not shown on the plot plan? YES NO xplain:
6. Are there any easements on the property? YES ONO
7. SITE INFORMATION: r t
a.What is the dimensions or acreage a parcel? ZOO/67C)
b. Is this a corner lot? YES (nigo
c.Will the grade be changed as a result of the construction? YES �Y
d.What is the water source? PUBLI PRIVATE WELL
e. Is the parcel on SEWER or a PRIVATE SEPTIC system?
Tan Building&Code Enforcement PrInrinla Stnirtora Rauluut Mardi)1.11R
DECLARATION:
I. lacknowledge that no construction shall commence priorto issuance of a valid building
perm and work will be completed within a 12 month period.,
2. If the work is not completed by the 1 year expiration date the permit may be renewed,
subject to fees and department approva i.
3. I certify that the application, plans and supporting materials are a t rue and complete statement
and/or description of the work proposed, that all work will be performed in accordance with the
NYS Building Codes, local building laws and ordinances, and in conformance with local zoning
regulations. -
4. I acknowledge that prior to occupying the facilities proposed 1, or my agents, will obtain a
certificate of occupancy.
5. I understand that !Awe are required to provide an as-built survey by a licensed land surveyor of
all newly constructed facilities prior to issuance of a certificate of occupancy.
•
I have read and agree to the above:
PRINT NAME: VIP dreo?/7
SIGNATURE: DATE: 006/
Too Building&Code Enforcement Prinrinla Stgnrt,.ra Rauicarl March 7mR
0
Y rl,
• '` ') SEPTIC DISPOSAL PERMIT APPLICATI ON Office Use Onl
` 742 Bay Road,Queensbury,NY 12804
P.518-761- 256 Perm # c2C—( }q-q-b 2.0 ktS
Tax Map ID#: Permit Fee:$ Invoice#:
Pro"ect Location: " i Septic Variance? Y„ N
Primary Owner(s) 1.- el
Mailing Address /6S 9 — q ' ' /242'
Phone & Email ,c/8 36 j—i7,V.2
Installer/Builder j/ / • 1 ( • 7i ie•
Mailing Address .
Phone & Email 1- i-apc/'
Engineer /4�/7 f7 4 �
Mailing Address /V f .
Phone& Email rjr d V
Contact Person for Building&Code CcDmpliancKMaw Phones:J7r7*7‘,17
INFORMATION:RESIDENCE
Year Built #of bedrooms X gallons per bedroom = totaldaily flow Garbage Grinder Yes
1980 or older: Installed? {circle one)
1981-1991 Spa or Hot Tub Yes No
Installed? {circle one)
ES2-Present ` w. !
PARCEL NFORMATION:
'-'
Topography at Rolling Steep Slope %Slope
Soil Nature (Send _Loam Clay Other
Groundwater At what depth? A./
Bedrock/lmperviousmaterial At at depth? 4/,
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 engieer/arcttect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size /000 gallons{min.size 1000 gaIlons,add 250 ga lions each garbage cylinder or spa/hot tub
System Absorption field with#2 stone Total length / ft.;EachTrench dt% ft.
Seepage Pit with#3 stone IHow many: Size:
Alternative System IBed or other type: __
HoldingTank System Total required capacity? tank size ;# of tanks
NOTES:1.Alarm system&associated electrica Iwork must be inspected bya Tow napproved 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.I
have read the regulations and agree to abide by these and all requirements oftheTown of Queensbury Sanitary Sewage
Disposal Ordinance.
PRINT NAME: .--4) . ei V'�. DATE:__ � �� A
SIGNATURE: 4 s".------ DATE:
Town of Queensbury Building&Code Enforcement Revsed February 2017
Office Use Only
FUEL BURNING APPLIANCE & Permit#: Ci—C-041-1—2-0 tb,
".....*
CHIMNEY APPLICATION
Permit Fee: $
invoice#:
-,I 01/06=0.5.-m .
742 Bay Road, Queensbury, NY /2804 P:
518-761-8256 www qt,, iv net
Project LocationXiaff/4 p. ak43 Tax Map ID:
Room of Installin; Az--:,
/ , Planned Install Date:
**ONE APPLICATI ON PER APPLIANCE**
CONTACT INFORMATION:
• Applicant:
Mailing Address, C/S/Z: /15:Ff PA.. , A. etVitatai zi-/ / 1---ar
Cell Ph.: Otr- ) 364- 974/z.....--- Land Line: (fij--) g"-O- 77.r/
Email:
• Primary Owner(s):
Name(s):
Mailing Address, C/S/Z: Ant r_ ./
Cell Ph.: ( ) •Land Line: ( )
Email:
• Installer/Builder:
Name(s): / 11 n' J--/Iget/A. - 4r,,
Mailing Address, C/S/Z: /744 /dine/ /filf--/ /77102/9fiV
Cell Ph.: ar) 8c-7-evo-3 (gee y) Land Line: ( )
Email:
Contact Person for Building & Code Compliance: a,mvii S- 4" __:
Cell Ph.: Cig ) 72,q-74/77 Land Line: ( )
Email:
•
Town of Queensbury Buildirm&Code Enforcement
FUEL BURNING APPLIANCE INFORMATION:
TYPE OF DEVICE:
Stove Fireplace Insert Fireplace
_Fuel Fired Equipment(Garage Only,B"clearance per IMC304.3)
_Fireplace, factory built*
** Manufacturer's Name: /'/" it / ti tv, Model#: •
SOURCE OF HEAT: -
Wood Coal Pellet Gas
CHIMNEY INFORMATION
Masonry:
block brick stone
Flue:
tie steel size,in inches
Material*: e
double-wall triple-wa II insulated
(*Manufacturer's r-i m - Model#: J7//7�
ADDITIONAL INFORMATION:
•
1. Two inspections are required. A rough-in inspection,prior to installation and a final inspection,after
installation.
2 Manufacturer's installation manual must be available at the time of inspection.
3 Masonry fireplaces & chimneys require plans to be submitted.
4 Twenty-four (24) hour notification is required for nspections.
Declaration:Construction/installation must conform to NYS Fire Prevention&Building Code and/or manufacturer
requirements.The applicant or owner agrees to comply with allapplicabte bws,ordinances,regulations and all
conditions that are part ofthese requirements and also will allow the inspector to enter the premises to perform the
required inspections.
I have read and agree to the above:
e ,moo
PRINT NAME: 4Artf
•
SIGNATURE
T :4/./1/1 Fuel Burning Appliance&Chimney Application
Town of Queensbury Thomas R.Van Ness -
'lieway 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: (, '�_, /11/geiNe -
Telephone No.: �l1 �—�f
Address to be Inspected: 15 / iti— L J A4,
- Return Address: ,40/� /- 9 / �. /0 (
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 2017