applications I/
, ,; PRINCIPLE STRUCTURE Office Use Only
` PERMIT APPLICATION
'r Permit#: a_C-02-14 Z -2 6-to
,;� , • Permit Fee:$ (.P.Lg, 14 0
742 Bay Road,Queensbury, NY 12804 *Rec. Fee:$ ',C-U• vO
P: 518-761-8256 www.queensburynet �G
Invoice#: S `k
Project Location: 7 6akex )2c
Tax Map #: k I .S-1^a 3 Subdivision Name:
TOWN BD.RESOLUTION 86-2013:$850 recreation eri r nePdvre_iling units=singleifamily, duplexes/two-family,
multiplefamily, apartments,condominiums, townho , n ir-rna ufactured_ mo,ular homes, but not mobile
homes. This is in addition to the permit fee(s). i c
'
CONTACT INFORMATION: i ," '
TOWN OF OlUEEN =E:.El v
• Applicant: BUILDING&CODES
Name(s): ift,Gov j p;C i, c ZL -
Mailing Address, C/S/Z: di ( 12,teye_ 2e) evuoihts6.1, AY 1 i$oV
Cell Phone: ( .51$ ) 9b1- 1'713 Land Line: ( )
Email: drum_ eL. GOLZ F. etaM
• Primary Owner(s):
Name(s): 6a - /.)pp 1,rr,,. -
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: ( )
Email:
❑ Check if all work will be performed by homeowner only
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): Qnlek M A-40- i l
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: ( )
Email:
**List all additional contractors on the back of this form
• Architect(s)/Engineer(s):
Business Name: kO&e-
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: ( )
Email:
Contact Person for Building & Code Compliance: .Ovid PACANDLLI,
Cell Phone: ( 6IS) ) 'L// 1- )71") Land Line: _ ( )
Email: Live.. a 6Dt F. toM
Principle Structure Packet Revised February 2019
PROJECT INFORMATION:
TYPE: Commercial S, Residential
WORK CLASS:
Single-Family Two-Family _Multi-Family(#of units )
Townhouse _Business Office _Retail _Hotel/Motel
_Industrial/Warehouse _Garage(#of cars ) _Other(describe )
STRUCTURE SQUARE FOOTAGE: GARAGE SQUARE FOOTAGE:
1ST floor: 77a 1'floor: qq
2nd floor: 'Mob 2nd floor:
3'floor: p
Total square feet: P13
Basement(habitable space):
Total square feet: Jy7a
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ 175;t
2. Proposed use of the building: 5i kw.;iy 1 ,2
3. If Commercial or Industrial, indicate the name of the business:
4. Source of Heat:Gas Oil rop Solar Other:
(Fireplaces need a separate Fuel Burning Appliances&Chimney Application,one per appliance)
5. Are there any structures not shown on the plot plan? YES 'V Explain:
6. Are there any easements on the property? YES NO
7. SITE INFORMATION:
a. What is the dimensions or acreage of the parcel? I AGEo_
b. Is this a corner lot? YES
c. Will the grade be changed as a result of the construction? YES NO
d. What is the water source? 1 [_ PRIVATE WELL
e. Is the parcel on SEWER or a PRIVATE SEPTIC system? SepC_
Principle Structure Packet Revised February 2019
DECLARATION:
I. !acknowledge that no construction shall commence priorto issuance of a valid building
permit and work will be completed within a 12 month period.
2. If the work is not completed by the 1year 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 true 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 I, or my agents, will obtain a
certificate of occupancy.
5. I understand that I/we are required to provide an as-built survey by a licensed land surveyor of
all newly constructed facilities priorto issuance of a certificate of occupancy.
I have read and agree to the above:
PRINT NAME: Dco d ,R5011,1r
SIGNATURE: DATE: 5/abiho
Principle Structure Packet Revised February 2019
Office Use Only
SEPTIC DISPOSAL PERMIT APPLICATION Permit#: ' 0 Pj2b
Permit Fee:$ : Invoice#:
Septic Variance? Yes No
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensburv.net
Tax Map ID#: 301 ,5-1-
Project Location: 7 i cXtu' 12.8
• Applicant:
Name(s): iNk911.501W Erkwpi eg 1 t`
Mailing Address, C/S/Z: L{l J?j PU . •2d oky Ay 1 2:00(
Cell Phone:_( 515 ) 4b1- 1713 Land Line: _( )
Email: OGUL ee CaoGZF. C.cWM
• Primary Owner(s):
Name(s):
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line: _(
Email:
❑ Check if all work will be performed by homeowner only
• Contractor: Workers' Comp documentation must be submitted with this application
Contact Name(s): C\nax'In4 Fit IMz,r`
Contractor Trade: C.\nni4o .. P,,Jt►or{ /NAO.• . I DrAl};�
Mailing Address, C/S/Z: .54 AttePA 6k.
Cell Phone:_( ) Land Line: _( 5i ) 747- 9371
Email:
• Engineer(s):
Name(s):
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line: _( )
Email:
Contact Person for. Building & Code Compliance: o_ti 40,Astak
Cell Phone: _( 6Ig) ) libl-17)3 Land Line: _( )
Email: mile r. cs✓v\
Principle Structure Packet Revised February 2019
•
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms: X gallons per =total daily flow
per day bedroom Garbage Grinder Yes
1980 or older 150 Installed? (circle one)
1981-1991 130 Spa or Hot Tub Yes I
Installed? (circle one)
1992-Present 110 7j I 3 3O
PARCEL INFORMATION:
Topography 7( Flat Rolling Steep Slope %Slope
Soil Nature 1[ Sand _Loam _Clay _Other(explain:
Groundwater At what depth? > eme_
Bedrock/Impervious material At what depth? t)
Domestic Water Supply ZC 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 engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size Imo gallons(min.size 1,000 gallons, add 250 gallons for each garbage cylinder or spa/hot tub
System Absorption field with#2 stone Total length i.c() ft.; Each Trench a ft.
Seepage Pit with#3 stone How many: 2, ;Size: SO
Alternative System Bed or other type:
Holding Tank System Total required capacity? ;tank size ;#of tanks
NOTES: 1. Alarm system and 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 and
approved.The installed system must match the septic layout on file—no exceptions. 3. As-built drawings must be
submitted prior to the inspection, if there has been a change to the submitted plans.
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 of the Town of Queensbury
Sanitary Sewage Disposal Ordinance.
PRINT NAME: D04,0 r1 JV10'A9 DATE: 51at,kr)
SIGNATURE: DATE: 5IJ b I][7
Principle Structure Packet Revised February 2019