applications •
° PRINCIPLE STRUCTURE
Office Use Only
PERMIT APPLICATI ON
Permit#: ' 0 • 2e'2_�
Town of Queens•ury Permit Fee: $ ciI'
3
742 Bay Road,Queensbury, NY 12804 *Rec. Fee: $ ��— I' °
P: 518-761-8256 www.queensburynet
Invoice#:
Project Location: �I: "1 JPF'( IZOAD
Tax Map #: I -13. 12-- Subdivision Name: /VA
TOWN BD.RESOLUTION 86-2013:$850 recreation fee for new dwelling units: Iftarylify, pifxt ,tw9 .�, ,
multiplefamily, apartments,condominiums, townhouses,and/or manufactured o la�'#iof sybut`kdr-rinpb -
homes. This is in addition to the permit fee(s). - ----
CONTACT INFORMATION: JUN 29 2Q20
TOWN OF QUEENSBURY
• Applicant: BUILDING& CODFS
Name(s): 'F 4 11 EAI PI:O P 12T( DEV L ,%o ENT
Mailing Address, C/S/Z: 20 D6ELOOOD coVK'i QUE.CniSt3vicN 1-.14 l2 O11
Cell Phone: ( 5 i 8 ) `19 b. 4 651-1 Land Line: ( ) A/A
Email: patter►8ti Ca% yma i l• corn
• Primary Owner(s):
Name(s): e 1..1 E. N1 STL.E
Mailing Address, C/S/Z: 5 VJ t kiCr STREET, I-GA15 BALLS, Nij I z$O )
Cell Phone: ( ) '-1'-1 - 81-1"1 Land Line: ( ) IVA
Email: e ee he rno.3 Q, cerv,
❑ Check if all work will be performed by homeowner only
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): VAT-TEN) PROPE>2T ( DEVELO f'IM
Contractor Trade: HOME Co+.isTie.oc--to"J
Mailing Address, C/S/Z: Zv p-t D&&,& o D GUv2T 1 auEEnIS aulaH , /vt j I ZeoLl
Cell Phone: ( 5 t`Y3 ) —14 (o -+4(o5,-i Land Line: ( — ) NA
Email: '-M-1-e n 8 d-1 C@ �-,C1ti 1� c evwi
**List all additional contractors on the back of this form
• Architect(s)/Engineer(s):
Business Name: RUC1r16M HAW— ARCa-i( TECTUi2E
Contact Name(s): ETI-(Ati HALL-
Mailing Address, C/S/Z: 13Lk I) t A-vGt1UE C 1_ENS FA L LS, tV 1 12Q,O I
Cell Phone: ( ) NA Land Line: ( 51$ ) 14-{1,- O2_66
Email: € c \\@ ( L.3CC , ir.C [r rr
Contact Person for Building & Code Compliance: CH Os fATTEJ
Cell Phone: ( 51`b ) r14(o• `-1(05'4 Land Line: ( ) PIA
Email: 4�-(;�.e yN 4�{ C Q Y►1 u i(, ar,v,
Principle Structure Packet[ 1 Revised February 2019
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): 1'RODUCTI O"J D P I
Contractor Trade: p1Zy WALL. HANG I "JG
Mailing Address, C/S/Z: 2 W I NDtl LANE
Cell Phone: ( ) 301 - 31:6612 Land Line: ( — ) NA
Email: NA
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): J D BOUCi-\Ei2 E►JT�e.P11SES , �t�G
Contractor Trade: CoNcee-r
Mailing Address, C/S/Z: 19) HA►2TMAN RD, }-(UDSotJ FALLS, MI 12433'
Cell Phone: ( 6"b ) 3(01- 211$ Land Line: ( ) NA
Email: bovc.herc ,cie+e6.) n,\sn.c -)--1
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): CHAi2 - -S ERI eDn ACJ EXCAVATING- i NG
Contractor Trade: SITE PREP
Mailing Address, C/S/Z: 51-1 NU2T1i ST, HUDSOt4 FANS '4y l2$39
Cell Phone: ( 51% ) 141- I Land Line: ( — ) i'lA
Email: ti sp.&f-vi edm excavcrf=inch c-lrw�
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): �, k •DQ'-(,
Contractor Trade: t.i WA LL- El 14 i S 1-4
Mailing Address, C/S/Z: 3iS 1''51'6. L RD+ Cote tJ , M4 17132 2-
Cell Phone: ( 5155 ) 36Co 16l4 Land Line: ( ) WA
Email: N Pc
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: (
Email:
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: (
Email:
Principle Structure Packet Revised February 2019
' PROJECT INFORMATION:
TYPE: Commercial 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: I(025 1ST floor: 214
2nd floor: N A 2nd floor: /✓A
3rd floor: WA
Total square feet: 6 24
Basement(habitable space):
Total square feet: 16 2-5
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ ' e ,Q(` J
2. Proposed use of the building: 1261ZScNAu R&51DeNICE
3. If Commercial or Industrial, indicate the name of the business: N Pc
4. Source of Heat: Gas Oil Propane 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 NO Explain:
6. Are there any easements on the property? YES 025)
7. SITE INFORMATION:
a. What is the dimensions or acreage of the parcel? R 3A 3 ACk�.S
b. Is this a corner lot? YES NO
c. Will the grade be changed as a result of the construction? YES N•
d. What is the water source? PUBLIC PRIVATE 00
e. Is the parcel on SEWER or a PRIVATE SEPTIC system? 'gWATE,
Principle Structure Packet Revised February 2019
DECLARATION:
I. lacknowledge that no construction shall commence prior to 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 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 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 IMre 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: 'Reis PA-TT
SIGNATURE: DATE: (o •
Principle Structure Packet Revised February 2019
Office Use Only
FUEL BURNING APPLIANCE & Permit#: e.G-060,6. 2S 2a
CHIMNEY APPLICATION
Permit Fee: $
Invoice#:
742 Bay Road,Queensbury, NY 12804
P:518-761-8256 www,queensbury.net
Project Location: (t-113L-1 SIAt/ ROAD Tax Map ID: Z(o&" , - 1 l2 .
Room of Install: LIVI nj& )ZOOM Planned Install Date:
**ONE APPLICATI ON PER APPLIANCE**
CONTACT INFORMATION:
• Applicant:
Name(s): PA PQo PC-R Ty pE VELD PM€NT, Le.G
Mailing Address, C/S/Z: ?-O (U O6-6-V00O D CT , ( u E ENS 4 u2-t, I Z-gILj
Cell Ph.: _( 51Is ) --KAitp-'-I b54 Land Line: ( -- ) NA
Email: ea“-e1e1 9rn&LP.co-,-,
• Primary Owner(s):
Name(s): E L 1 C . em-rwis -r-LE
Mailing Address, C/S/Z: 5 wlk16- ST, GLENS F-/+LZS, MVJ in01
Cell Ph.: _( 51 8 ) 1 Li -(-(6411 Land Line: ( -- ) NA
Email: a vl I s e e C hbtr►vkA.e.QY✓l
El Check if all work will be performed by homeowner only
• Installer/Builder: Workers' Comp documentation must be submitted with this application
Contact Name(s): PA TTEN PROPER-( DEVeU0eNtei.f ', 1-L
Contractor Trade: Home, C &JSrie X ii o�l
Mailing Address, C/S/Z: ?p e-IOG 6fX.DD CT , Q,.UEENS 3v 2-4 , Ill- 174014
Cell Phone: _( 51%, ) 19(p' l(061-1 Land Line: _( +- . ) !JA
Email: 1)6A1ev‘t L-t e lyb-la,i I. t '-ram►
Contact Person for Building & Code Compliance: O.-WI S '(9/T1 EMI
Cell Ph.: ( 51% ) la (o• '4(o5 t Land Line: ( — ) NA
Email: pa4-e►l 814 CA' ofvyl ci;,l.cowl
Principle Structure Packet Revised February 2019
•
FUEL BURNING APPLIANCE INFORMATION:
TYPE OF DEVICE:
Stove Fireplace Insert Fireplace
_ Fuel Fired Equipment (Garage Only, 18" clearance per IMC 304.3)
V Fireplace, factory built**
(**Manufacturer's name: MAJ EST1c Model #: 3fc"
SOURCE OF HEAT: /
Wood Coal Pellet v Gas
CHIMNEY INFORMATION:
Masonry (require plans to be submitted): IJA-
block brick stone
Flue: ti
tile I steel size, •in •inches
✓Material*:
double-wall _triple-wall insulated
(*Manufacturer's name: M f1J EST1G Model #: ZA)A-eTZ
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 inspections.
5. Workers' Comp insurance information is required with this application.
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 the inspector to enter the premises to perform the required
inspections.
I have read an ree to the above:
PRINT NAME: S R14441
SIGNATURE: DATE: 6/7-6/
20
Principle Structure Packet Revised February 2019
Office Use Only
1°"" `je'n'b"". SEPTIC DISPOSAL PERMIT APPLICATION Permit#: .C..O J•LoLo
Permit Fee:$ ; Invoice#:
Septic Variance? Yes No
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net
Tax Map ID#: 02(06 . - 1-, 3• i a
Project Location: \ �31-1 1 Ron D
• Applicant:
Name(s): eRUPE °EVe teicEkfr, Li—L-
Mailing Address, C/S/Z: 7-0 gAPC-t"L--vVCOb Cr( al)GENS f3v12N , " t 124014
Cell Phone: _( 5 l g n q,(. -4(1p 5`1-4 Land Line: ( — )
Email: ca �n�-► e 9 mck-t l•
• Primary Owner(s):
Name(s): 1✓(_i NTWIS*'LE
Mailing Address, C/S/Z: 5 W �NC� ST (D NS FALL S NN 1240 I
Cell Phone: _( S i R ) 1+-1+-1- 8C1'"1'"1 Land Line: _( ) MA-
Email: en-I'Lkia-ge Viptma,L•Gcrrv-1
❑ Check if all work will be performed by homeowner only
• Contractor: W rkers' Comp documentation must be submitted with this application
Contact Name(s): C I/1,w 1(5 trn'e rvul
Contractor Trade: #� Ck v-.41.;1"
Mailing Address, C/S/Z: IIJt)vl- 1 Stre-e f ttArison j-u It S
Cell Phone: _( 5if ) .361 - 171/f Land Line: _( )
Email:
• Engineer(s):
Name(s): I 1 CN ►f4S &r(Gti N E-E121 K)C,
Mailing Address, C/S/Z: I(o9 HAVtLAW 1209-13, WeE(JS8V(2 4 , AA17Z0I+
Cell Phone: _( ) Land Line: _( 5 It ) 7 -0307
Email: IOM i-tuti -tINS - 4-htx-i-chins6 KO-chi oS eilitleerung Ic
Contact Person for Building & Code Compliance: CFRIS 1941 1EN
Cell Phone: ( 51$ ) 1q(o ,14(05'} Land Line: _( — ) N4-
Email: Qalten8409rnaa•60w)
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 �N
1980 or older 150 Installed? (circle one)
1981-1991 130 /\ Spa or Hot Tub Yes No
Installed? (circle one)
1992-Present 110 ?, \ 0 33U
PARCEL INFORMATION:
Topography Flat Rolling Steep Slope %Slope
Soil Nature ✓ Sand '/ Loam _Clay _Other(explain:
Groundwater At what depth? > g-Fee--
Bedrock/Impervious material At what depth? >g-F -r
Domestic Water Supply _Municipal /Well(if well,water supply from any septic system absorption is>1obft.)
Percolation Test Rate: per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEMtt� FOR NEW CONSTRUCTION:
Tank size I�� O 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 Z-00 ft.; Each Trench 5 0 ft.
Seepage Pit with#3 stone How many: ./VIF ; Size: ✓' 1k-
Alternative System Bed or other type: /✓4'
Holding Tank System Total required capacity? 4 / ;tank size AA-- ;#of tanks .�4:0---
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: c 1 S PA I Itn DATE:
SIGNATURE: DATE: 6 70
Principle Structure Packet Revised February 2019
David Duell
Town of Queensbury
Highway Superintendent
Highway 4F"
518-761-8212
Department r�y
742 Bay Road-Queensbury,NY Mark Benware
12801 Deputy Highway Superintendent
Phone: (518) 761-8211 518-761-8210
Fax: (518) 745-4466
DRIVEWAY PERMIT
DATE: • 1 c1 • "2-0-2-0
APPLICANT NAME: PA-rTEN PeQPE art-1 D6VEL-OeMENT, LL-G
TELEPHONE NO.: 5 ‘45 '-lq lo•y 6 S14
ADDRESS TO BE INSPECTED: 1'AI -1 BPS'-! Ro \D
RETURN ADDRESS: 2b 11 D G Etiv (j P Goti te 7
)e6nis r3vet_i awl 17-00y
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 approved permit for a final approval.
STEP 2: ( ) Final Approval ( ) Rejected
Date:
David Duell, Highway Superintendent Mark Benware, Deputy Highway Superintendent
Office Use Only
FUEL BURNING APPLIANCE & Permit#: 2C,- ® 5,
CHIMNEY APPLICATION Permit Fee: $
Invoice#:
Tann of Queen sbury
742 Bay Road, Queensbury, NY 12831.
P: 518-761-8256 www .queensbury net
Project Location: 1434 Bay Road Tax Map ID: 265.-1-73.12
Room of Install: Basement Planned Install Date: September 2020
**ONE APPLICATI ON PER APPLIANCE**
CONTACT INFORMATION:
• Applicant:
Name(s): Eli Entwistle
Mailing Address, C/S/Z: 7 Wing Street, Glens Falls NY 12801
Cell Ph.: 518-744-8977 Land Line: ( )
Email: entwisee@hotmail
• Primary Owner(s):
Name(s):
Mailing Address, C/S/Z:
Cell Ph.: ( ) Land Line: ( )
Email:
• Installer/Builder:
Name(s): Patten Property Development
Mailing Address, C/S/Z: 7 Jackson Road, South Glens Falls NY 12803
Cell Ph.: 518-796-4654 Land Line: ( )
Email: patten84@gmail.com
Contact Person for Building & Code Compliance: Ethan Hall — Rucinski Hall Architecture
Cell Ph.: 518-260-2888 Land Line: 518-741-0268
Email:ephall@nycap.rr.com
Principle Structure Application Revised January 2019
FUEL BURNING APPLIANCE INFORMATION:
TYPE OF DEVICE:
®Stove ❑Fireplace Insert ❑Fireplace
❑Fuel Fired Equipment(Garage Only, 18"clearance per IMC 304.3)
❑Fireplace, factory built **
** Manufacturer's Name: Model#:
SOURCE OF HEAT:
N Wood ElCoal ❑Pellet ❑Gas
CHIMNEY INFORMATION:
El Masonry (requires plans to be submitted):
❑ block El brick ❑stone
❑ Flue:
❑ tile steel 10 size, in inches
❑ Material*:
►z� double-wall ❑ triple-wall ❑ insulated
(*Manufacturer's name: Model#:
ADDITIONAL INFORMATION:
1. Two (2) 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 all applicable laws, ordinances, regulations and all
conditions that are part of these requirements and also will allow the inspector to enter the premises to perform the
required inspections.
I have read and agree to the above:
PRINT NAME: Etha Hall A r•i 'te \Agent for the Applicant
SIGNATURE: • DATE: 20 July 2020
Principle Structure Application Revised January 2019