application Office Use Only
,
11-fr;TIP:h PRINCIPLE STRUCTURE PERMIT 1. Permit
APPLICATION I Permit Fee:$ Ct / LI, ST i
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.*Rec. Fee: $ (175-6). U ° 1
742 Bay Road Queensbury. NV .2804
P 518-761-82$5.,_2,A c \ ii HrtWC :
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Project Location: Oka' ',A ''' Ern)t-e Ric( - 'iDj JUN 1 2 2018 'j d .
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Tax. Map #: 30g .8 - I-2 i , ta ft Agr'- iSubcfli4fig#46,i'e:,:taWOVFRIFAcktl.
TOWN BD RESOLUTION 86-2013 S850 recreation fee for new dirv-eilinb dri-: ,..:;;;:-:, -Zi-ol'Irdi.Tp---,,, ... two-family,
multiple family apattrnents c,o,lciom,niums tovir,ric.ctse•:,.. and.r_v; manufactured ,,,:. roo.1Waf homes but no M--.)bl'e
homes This is in addition to the permit fee(s).
CONTACT INFORMATION: ,
@ Applicant:
Name(s): (.)D T H I 1-(-5 BLA.it_i) E.KS (lb E
Mailing Address, C/S/Z: 1 moutJTAtikicibe- bRive- . aute:&.-1-Jst.a.1 P'r' 12-r0 1
Cell Ph.: I ( SI ) -Vi I - iq . 3 Lend-L-4-1e: it (s-/T. ) /96-3s-2-0 (_ '-)
Email: Fc01-011... 5,), i-DE.As ts"-f g C-rniti L.. cc t.o. .
0 Primary OWnar(si:
Name(s): SP\(Y) - AS A ppi_i c.AN-r
Mailing Address, C/S/Z:
Cell Ph.: ( )__ Land Line: .( )
Email: -
6 Contractor(s):
Name(s): S A rr\ AS A P e Lk C.("AN--1
Mailing Address, C/S/Z:
Cell Ph.: ( ) Land Line: ( )
Email:
a ArchitecttsVEnpineer(s): Eiti qr.: BAL-I- (3L1` DM_ Okr6 G-LENg EALks 0-1
12i-0 1
. - • I
Mailing Address, C/S/Z: - ' ' •
Cell Ph.: _( ) Land Line: I. ( S ' ? ) ---'-----7-;-7:.- -"11*'-' lq I -0 2-(et
ET 1-1A1-1- iv c_AP. g_g_, <ATI\
Email: .
Contact Person for Building & Code Compliance: 30.6.- 1-6kk L I
Cell Ph.: f (Til ) -01- 1133 Etrrtd Line: i (
Email:
Princitila St risr tyrP Riz''ASPCI March 701R
MO Suilrime R.rorIP Frziarcc-chcqa
PROJECT INFORMATION:
TYPE: Commercial X Residential
WORK CLASS:
Single-Family _ Two-Family Multi-Family(#of
Townhouse Business Office Retail Hotel/Motel
Industrial/Warehouse Garage(#cif cars ) Other(describe
STRUCIURE SQUARE FOOTAGE: GARAGE SQUARE FOOTAGE:
isTlicior: 9 I 0 IF-floor: :23 I
2nd floor: rd floor:
3m1 floor:
Total square feet: 2-3
Basement(habitable space): 5".
Total sqmre feet: "1 C
ADDITIONAL PROJECT INFORMATION:
I. Estimated Cost of Construction:$ I -7 000
2. Proposed use of the building: ESLDI .ILAL "Tw
S. If Commercial or Industrial,indicate the name of the business:
4. Source of Heat(circle one): 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 tgraotain:
6. Are there any easements on the property? YES No
0,C0rz-
7. SITE INFORMATION; o,
a.What is the dimensions or acreage of the parcel? 0?-44&7-'44-9"tilarl
b. Is this a corner lot? YES IL
C. Will the grade be changed as a res he construction? tai) NO
d.What is the water source? 7 mu« PRIVATE WELL
e. Is the parcel on SEWER or a PRIVATE SEPTIC system? Se-PT I(--
%Ce-t— A-TrAc 14 Cb C-P-AbiN6- FLA?-)
TOO tliStilriF EnfarePnlAn1 Prinrinin Stroortstra RPViCL?fi Ntirrh 711114
DECLA 4,1410N:
I. I acknowledge that no construction shall commence priorto issuance of a valid ouildi ng
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. 1 certify that the application, plans and supporting materials are a true and complete statement
arid/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 liWe are required to provide an as-bui ft survey by a licensed land surveyor of
all newly constructed facilities prior tO issuance of a certificate of occupancy.
have read and agree to the above:
PRINT NAME: 3-6 Ep LEtA,
SIGNATURE DATE: 8
•
PrinrinIP cantrivra RpvicAri Marrh 7rnsc
Tota Building EL Code triforcment
1 4 _ ft•
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vi.';34.7-•::i''ji,,, 1
t_.:: .i-.,,.;:i SEPTIC DISPOSAL PERMIT APPLICATION :
•---.47*.7,6! i ,z-1.,-. •.:-.----,4:7;
"6""..1" 7-' Say Road.Qw.-.::nisbury,\', 11-1 i
.P 5IS 76 • • s6 f Perm•
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Ta.. TV1p lb# 3o,.e-_ ,.g.,:j:- _/. ,_q I_,, , .. . ,, . -,l .-,,, ,-, . ._
3 o F-• - t -zi, ,,..,1;!. LI 2_ • I
Project Location:
1/1 Primary Owner(s) ,---, ;
•s r T OC H tt---1-S av•1 Lbeg /..1 ( CS 0 c Levi c_i) .
._ ........._. ______ • •
_....
it Mailing Address
4-- . il rtA01-sk-NTA INS ID e bk GIA -'r,, LS,f,.•,,f4,1 t--,j ./2go\1
II Phone & Email (S-if.)Ill-/q33 / (St 019&- s sac icciti(L-Ls 8(A i Lm-gs NI ce6-rAfiii.-atY1
... .. .. .
. Installer/Sul/der
SE"
• .. . — • -1
•
Mailing Address I
. . .
' • ..,_ . , , -1
li Phone & Email .
1
1-t rf\ C_EN-t.e.12- P
s lvlailing Address ,.,- - ' ' ...,,
Phone & Email 15' TCGNICR3C4 € YAI-job, CorY\ i
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a Le,t.Lf
Contact Person for Building&Code tz:›rrs.1::11 karic----- : 1= n.s.: Cs 1 )--7'1 I - ici33
RESIDENCE NFORMATION:
.
i Year Built # of bedrooms X gallons per be0roorn i = totaidaily flow Garbage Grinder i Yes 0 .
/
80 Pr older
I Installed? {oirdle one) i
1 -1981-71991 .
— ----' Spa Or Hot Tub
Yes -
Installed? {circle one)
..-_____ „92-PreSent; 3 1.1 I 16 3.- .
. 3 0 • - ,. - --
[
PARCEL NFORMATION:'
___
1 Topography P
-- 2-A ii Ft Roiling e %Slope Steep SloP
l'-' •
1 Soil S „
_Other
Groundwater and Loam Clay
—
1 Groundwater . At what depth? .skfc,
., ._ _
rBedrockilmpery bus material At what depth p./0
_ _ . _.
I Domestic Water SupA, AlManicipal _ Well irif well.water supply from any septic system ab.sorption is II.)
• ________ ,,
! Percolation Test i Rate. j -r per minute per inch{test to be completed by licensed encheerlarcilect)
! PROPOSED SYSTEM FOR NEW CONSTRUCTION:
1
I Tank SiZe 1 0 0 0 gallons{min.size MO gallons,add 250 ga Hone for each garbage cylinder or spa/hot tub
-
1 System I Absorpti on field w ith#2 stone Total ngth p----ti.:Each Trench /s.--6 ft.
t_ I :_... _f_—_—_---
Seepage Pitwith#3 stone How many:_ :Size:
r Alternative System — ---,Bed or other type: _
• —
_____________ . - .___ ________ _ •
1
•1 _____HoldingTank System Total'required capacity? stank size :# of tanks
. '
NOTES: lAlarm system&associated electrica twos*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'e received and approved.
The installed system must match the septic layout on file-no exce,ptions.
Declaration:Any permt 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 of the Town of Oueensbury Sanitary Sewage
Disposal Ordinance.
PRINT NAME: 30 S EP 1 Leac---I - DATE
SIGNATURL ___-,1 IVN •-•- DATE: (e• itylie
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