applications i
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PRINCIPAL STRUCTURE APPLICATION Office Use Only
DATE q/e —Raceiuid
CC_ _l ( 0 7 Tax Map ID
TAX MAP ID ��.J r/ D Per it No. 2o►0j-b Pp lQ
3 � Y2C./Cd
ZONING t APR 13 2015 Pet ee c50 Y> d
—Ste PI n#
HISTORIC SITE Yes No TOWN OF QUEENSr iv ion#
BUILDING& CC,
...: .., Lam,
SUBDIVISION NAME 67;7`J Lot#
TOWN Ba RESOLUTION 86-2013: $850 RECREATION FEE FOR NEW DWELLING UNITS, INCLUDING SINGLE FAMILY DWELLINGS,
DUPLEXES OR TWO FAMILY DWELLINGS, MULTIPLE FAMILY DWELLINGS, APARTMENTS, CONDOMINIUMS, TOWNHOUSES, AND/OR
MANUFACTURED&MODULAR HOMES, BUT NOT MOBILE HOMES. THIS IS IN ADDITION TO THE PERMIT FEE.
APPLICANT Ard ,44i Au1Q"G/' OWNER 5/4,1-Q
ADDRESS /‘:_5"-- £/,2A /�C• ADDRESS
b�, (- - i�E yi
PHONE/E-MAIL.5V`.3(/ 3 U if PHONE/E-MAILV t-rAfr%Lf✓.i►1 ZA,--ckc-/'k A4/r/&.0,-)
CONTRACTOR S4' C COST OF CONSTRUCTION(ESTIMATED): $ 350. C.")
ADDRESS: BUILDING ADDRESS: 'x"// At 'SS/%9 D/
PHONE/E-MAIL
CONTACT PERSON FOR BUILDING& CODES COMPLIANCE: AA Ave //
PHONE 915 a g
TYPE OF CONSTRUCTION
Check all that apply Please indicate measurements as required below
New Addition Alteration 1st floor sq. ft. 2nd floor sq. ft. Total sq. ft. Height
Single Family eer. /6„?( ‘%/ Jc7? ?7J
Two-Family
Multi-Family
(# of units )
Townhouse
Business Office
Retail - Mercantile
Factory- Industrial
Attached Garage
(# of )
Other
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Town of Queensbury Building&Codes Principal Structure Application July 2014
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If commercial or industrial indicate name of business
Proposed use of building or addition �,,�,
Source of heat (circle one) '/6;25i Oil Propane Solace Other
Fireplace: complete a separate application for Fuel Burning Appliances &
Chimneys / 6A4: Wck.."42
Are there structures not shown on plot plan? Adi0
Are there easements on the property? p/117- %r' 64,12
Site Information
a. Dimensions or acreage of lot 30
b. Is this a corner lot? N
c. Will the grade be changed as a result of construction Yes X No
d. Public water or Private well G� G
e. Sewer or Private Septic System Pdrv,9 T{ 'PTS Sys? 'i
Value of all work to be performed (labor or materials) $ '5 0290
DECLARATION:
1. I acknowledge no construction shall be commenced prior to issuance of a valid permit and will be completed
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
department approval.
3. I certify that the application, plans and supporting materials are a true and complete statement / description of
the work proposed, that all work will be performed in accordance with the NY State 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 also understand that I /we 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: e i-cJ �7 DATE /—/G'
SIGNATURE: .9 Or. 1, DATE
FOR OFFICE USE ONLY
Operating Permit Issued: Yes No
Occupancy Type
Construction Classification
Assembly Occupancy Limit
Special Conditions
2
Town of Queensbury Building&Codes Principal Structure Application July 2014
fil? lECEnu - m��
4.401 i
SEPTIC DISPOSAL PERMIT APR 2
DATE -/CJ ./S TOWN OF QU 42eceivetY
C3 lILDING s
r j -i Tax Map IQ .
3
TAX MAP ID /. _ • -/ '�7 > Permit No.
� � his" Permit Fee
LOCATION OF INSTALLATION '9f/ ,A • :) !/1�/19 Approvals:
APPLICANT ( •
et G n h it./ /2 1/ PHONE/E-MAIL 36/-3 g 79
ADDRESS ‘63— /�/ iL d Z ' e 1,./2,-e ./t/. /)-Sl y1
INSTALLER/BUILDER: s�'`G' PHONE/E-MAIL ��L��
ADDRESS: .5 ej
OWNER 94 - PHONE/E-MAIL $
Address 54".C
CONTACT PERSON FOR BUILDING&CODES COMPLIANCE: 1 ,- L; 17 PHONE‘/3 32
RESIDENCE INFORMATION
Year Built #of bedrooms X Gallons per bedroom =Total Daily Flow
1980 or older Garbage grinder installed )(Y _N
1981-1991 Spa or Hot Tub installed )Y _N
1992-Present j' I
PARCEL INFORMATION
Topography Flat rolling Steep slope /0 %slope
Soil Nature X Sand Loam Clay Other
Groundwater At what depth?
Bedrock I Impervious Material At what depth? /U
Domestic Water Supply K Municipal Well(if well,water supply from any septic system absorption is ft.)
Percolation Test Rate: 1,/1 per minute per inch(test to be completed by licensed engineering/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION CL 9 : /c.),Y+ /C (-4" /L-7 -3;5) -dt 9
Tank Size /..5-cid 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 3 x e.-
Seepage
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 longer
allow systems to be covered until such time as an As-Built plan is received&approved. The installed system must match the septic system
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 know by or on behalf of an applicant, shall be void. I have read the regulations
and agree to abide by these and all requirements of the Town of Queensbury Sanitary Sewage Disposal Ordinance.
Print Name: ,i,/q... a /-,G Date: "1/-70-/S
Signature: Date: L/-/D -/
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, REQUIREMENTS
Two (2) sets of the following documentation with the application and fee:
1. Principal Structure Application (pages 1 & 2)
2. Plot plan drawn to scale with the use of a survey map, if possible (40 scale = 40 feet)
a) Plot plan drawn to scale with the use of a survey map, if possible (40 scale = 40 feet)
b) Indicate proposed structure(s), showing setback dimensions from all surveyed property lines
c) Show location of all existing structure(s) on the property
d) Show location of water supply (well or water lines)
e) Show location and configuration of septic disposal system or sewer line.
3. Structural drawings to include:
a) Floor Plan
b) Foundation Plan
c) Cross Sections
d) Elevations
e) Window and Door Schedule—see attachment
f) Calculation Sheet for Natural Light, Ventilation & Emergency Egress—see attachment
4. Registered Architect or Engineer's Stamp (signed & sealed) under the following circumstances:
a) Residential addition or alterations with construction costs over $20,000
b) Single Family dwelling 1,500 sq. ft. or greater
c) Any commercial construction
5. Checklist for single family or multiple dwelling or commercial project (page 4)
6. REScheck or COMcheck signed & stamped: Downloadable version —www.queensbury.net
7. Fireplace and/or woodstove solid fuel burning application, if applicable (page 5)
8. Septic Disposal Permit, if applicable (page 6)
9. Electrical Inspection Agency— please see"Certified Electrical Form: on town webstie
10. Driveway permit, if applicable (page 7)
11. Fee
NOTES
1. Certificate of Occupancy: Before a Certificate of Occupancy is issued for a new residential or commercial
structure, as as-built survey [plot plan] certified by a NYS licensed surveyor must be filed with our office.
2. Changes to Plan — Any changes prior to or during construction will require submittal of amended plans
(review and re-approval are necessary)
3. Withdrawn Permits: 20% of the initial fee is retainable by the Town. No fee is refundable after 1 year from
initial application date.
4. Additional review: All applications are subject to Zoning Administrator, Code Compliance and Structural Plan
Review.
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Town of Queensbury Building&Codes Principal Structure Application July 2014
' CHECKLIST - SINGLE FAMILY PROJECT
Project name:
REQUIRED -2 sets of the following documentation Yes No N/A
1. Building permit application completed
2. Energy Code inspector's report from REScheck
3. Septic alteration (if applicable)
4. Solid Fuel Burning or Gas Appliance form (if applicable)
5. Driveway Permit
6. Structural Drawings
a. Floor plans
b. Foundation plan
c. Cross Sections
d. Elevations
e. Window & Door Schedule
f. Natural Light, Ventilation and Emergency Egress
g. Plans signed /sealed by registered architect or engineer
7. Plot plans: indicate proposed structure, showing setback dimension from all surveyed
property lines
a. Show location of all existing structures on property
b. Show location of water supply (well or water lines)
c. Show location and configuration of septic disposal system or sewer line
8. Electrical inspection agency selected
CHECKLIST - MULTIPLE DWELLING / COMMERCIAL
Project Name:
REQUIRED - 2 sets of the following documentation Yes No N/A
1. Building permit application completed
2. Energy Code COMcheck and inspector's report form
3. Septic alteration (if applicable)
4. Solid Fuel Burning or Gas Appliance form (if applicable)
5. Driveway Permit
6. Structural Drawings
a) Floor plans
b) Foundation plan
c) Cross Sections
d) Elevations
e) Design loads including floor, snow load and wind load
f) Seismic design
g) Plans signed and sealed by registered architect or engineer
h) Window & Door Schedule
7. Plot plan— indicate proposed structure, showing setback dimension from all surveyed
property lines
a) Show location of all existing structures on property
b) Show location of water supply (well or water lines)
c) Show location and configuration of septic disposal system or sewer line
8. Electrical inspection agency selected
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Town of Queensbury Building&Codes Principal Structure Application July 2014
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. FUEL BURNING APPLIANCE & CHIMNEY Office Use Only
APPLICATION
Received
DATE —/Q.-` Tax Map ID
Permit No.
TAX MAP ID3/c
Permit Fee
ZONING 1/11 /'
OWNER: PHONE/E-MAIL '67 3 7g
ADDRESS G �C.a/1�� ,eCc L./re
L.2�,•C Q- s' /�Z }'�"
INSTALLER/BUILDER: 54 e PHONE/E-MAIL
ADDRESS: //� #//°
CONTACT PERSON FOR BUILDING& CODES COMPLIANCE: /e h Ar /4PHONE 3( JJ`�
BUILDING ADDRESS: 9/ /9C E'SSS/ (241I' /o
Fuel Burning Appliance Information Wood Coal Pellet Gas Oil NOTE: ROUGH-IN & FINAL
Stove INSPECTIONS ARE REQUIRED.
Fireplace Insert t
Fireplace, Factory built*
Fireplace, Masonry
Furnace (Garage Only)
"If Factory built provide manufacturer name: ; model#:
Listed by: Number:
Chimney Information
Masonry** (check one) Block Brick Stone
Flue Tie l Steel Size in inches
Material Double wall Triple wall Insulated V Direct Vent Chimney Liner
"'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: 46 ( /1 X47/ Date:
Signature: � Date: iT 67a
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Town of Queensbury Building&Codes Principal Structure Application July 2014
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: /G`-/
Applicant Name:
Telephone No.: 3(/ " :3 X70
Address to Be Inspected: i/ AtcSs it D7?
Return Address: i2/>4 Rc
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
O 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
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Town of Queensbury Building&Codes Principal Structure Application July 2014