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applications PRINCIPAL STRUCTURE APPY CATION Office Use Only
�j s
DATE Received
Tax Map ID
TAX MAP ID ��• ,� _ � " Permit No. l?C-ccC� l
Permit Fee
ZONING Rec Fee s► b
-19
Site Plan#
HISTORIC SITE Yes No Subdivision #
SUBDiyisioN NAME 74h Q. P"'? Lot#
TowN BD.RESOLUTION 8$-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 Aelil),L �&////-I _ OWNER
ADDRESS X I fk / ADDRESS
PHONE/E-MAIL f% PHONE/E-MAIL
CONTRACTOR COST OF CONSTRUCTIO'N/ ESTIMATED): $110, 000j
ADDRESS_ BUILDING ADDRESS:
PHONE/E-MAIL �p / �g (7
CONTACT PERSON FOR BUILDING&+CODES COMPLIANCE: �-C��� _ _,—PHON / HCl -
TYPE OF CONSTRUCTION
Check all that apply Please indicate measurements as required below
New Addition Alteration yeti floor sq. ft. 2"d floor sq.fit. Total sq,ft. Height
ef
Single Family
Two-Family
Multi-Family
(# of units---)
Townhouse ;WN 16 2016
Business Office
Retail - Mercantile
Factory- Industrial
Attached Garage
(# of
Other
1
Town of Queensbury Building&Codes Principal Structure Application July 2014
If commercial or industrial indicate name of business
Proposed use of building or addition
Source of heat(circle one) Gas 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'?'
Site Information
a. Dimensions or acreage of lot ,
b. Is this a comer lot?
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. 1 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. 1 certify that the application, pians 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. 1 acknowledge that prior to occupying the facilities proposed,t or my agents will obtain a certificate of occupancy.
5. 1 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.
1
I have read and agree to the above: PRINT NAME: i' DATE i t
SIGNATURE: DATE _
F_0R OF_7cE uSg oNL
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.
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: 16AK A
Applicant Name: f
Telephone No.: 6 /f Z%__,_
Address to Be Inspected: rf
Retum Address: �!
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 O Slight Swale
( ) Deep Swale
.11IN 16 2016
( ) Level with the road
{ ) Level with the top of the paved wing
Size culvert pipe to be used(if necessary)
( ) IT ( ) 15" ( ) 18" ( )24" ( )36"
Preliminary inspection completed by: Crate-
Approval by Highway Supt.: ;(or)D$pty Supt. . .
Upon completion please resubmit this approval permit fora final.approval.
STEP 2: ( ) Final Approval ( )�tejebted
Date:
Thomas R.Van Ness,Highway Superintendent David puetl, Deputy Highway Superintendent
7
Town of Queensbury Building&Codes Principal Structure Application July 2014
Fuel Burning Appliance & Chimney Application office Use Only
Received
DATE: Tax Map ID
TAX MAP ID: Permit No.
Permit Fee
ZONE:
OWNER PHONE/E-MAIL , © Z�
ADDRESS al d— AW Zi
INSTALLER/ PHONE/E-MAIL
BUILDER G- /� �F/aloe--
CONTACT PERSON FOR BUILDING&CODE COMPLIANCE:
PHONE/E-MAILBUILDING ADDRESS
ROOM OF INSTALL: Z&6// PLANNED INSTALL DATE: ''
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: Model#:
Listed by: Number:
j1 IN 6
CHIMNEY INFORMATION
Masonry" (check one) BLOCK BRICK STONE
Flue' TIE STEEL Size in inches
Material DOUBLE WALL PLE WALL INSULATED
** If non-masonry provide manufacturer name: /L— ;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: o &"M—e DATE: fA
SIGNATURE: DATE: lI
Town of Queensbury Building&Codes Principal Structure Application Revised September 2014
SEPTIC DISPOSAL PERMIT
Office use aft
�116/
DATE ; l: Received
tp
Tax Map ID
TAx MAP 1D j 1 I P�r t�t
// Permit ee
LoCATfoNOFINSTALLATION /�� L J � Approvals:
APPLICANT iL U f� PHONFI E-MAIL
ADDRESS Z
INSTALLERIBUILDER: !_ h1 4A",/ % �+C. ZA71AA_. / PHONE/E-MA1L
ADDRESS:
OWNER !�I?_..#X-e l� - PHoNEI EMAIL�J�'y'7'►
Address �j /
CONTACT PERSON FOR BUILDING&CODES COMPLIANCE: . IrYv Ll l� "_d PHONE_�
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 Not Tub installed Y N
1992-Present Zk O6
PARCEL INFORMATION
Topography Flat rolling Steep slope %slope
Soil Nature Sand Loam Clay Other
Groundwater At what depth? am
Bedrock/Impervious Material At what depth? 440
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 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 7,02 ft.;Each trench x D
Seepage Pit with#3 stone Now many; —;size
Alternative System Bed or other type?
Holding Tank System Total required capacity? Tanis size #of tanks
Notes: 1)Alarm system&associated electrical work must be inspected by a Town..approvedalectrical 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 rellance upon any material representation or
failure to maize 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 the!WX all quirements of the Town of Queensbury Sanitary Sewage Disposal Ordnance.
Print Name: Date:
Signature: Date;
6
Town of Queensbury Building&Codes Principal Structure Application July 2014