application Office Use Only
TOWN BOARD APPLICATION Received
MOBILE HOME OUTSIDE MOBILE HOME PARK Tax Map ID
C � l Permit No.
DATE: ` Z 2---- Permit Fee
TAX MAP ID
l5a � V 15
PROPERTY LOCATION:NAME OF MOBILE HOME PARK: EDRp
15 2018
PROPOSED DATE OF PLACEMENT: OF QUEENSBU Y
BUILDING&CODE
APPLICANT 1 t� 11
ADDRESS 5 0(y� 1CA ADDRESS
PHONE 1 1 �U S _ PHONE 1 µ COB- 5-to 1�)
ck
CONTACT PERSON FOR BUILDING&CODE COMPLIANCE: � Ln) nd t/�y
MOBILE HOME INFORMATION
New Home or Replacement: 06-0 ')HO t Year
Singlewide or Doublewide Make
Size of Mobile Home ft.x _' It. Model
Approximate Value of Home �C=( Serial #
State fully the reasons for this request:
DECLARATION: I swear that to the best of my knowledge and belief the statements containing in this application, together with the
plans and specifications submitted, are a true and complete statement of all proposed work to be done on the described premises
and that all provisions of the Building Code, the Zoning Ordinance, and all other laws pertaining to the proposed work shall be
completed with,whether specified or not, and that such work is authorized by the owner
✓Print Name: I �.I it Owner,Agent,Contractor Date:
✓Signature: Date:
DECLARATION: I swear that the used mobile home that will be transported into the Town of Queensbury for placement will have
the following:
a) A building permit approved and issued
b) Meet all zoning requirements
c) Mobile Home's HUD sticker affixed to the mobile home
d) Meet HUD requirements for the Middle Zone
As the person responsible for the transport and placement of the mobile home, I accept total responsibility for removal of the
mobile home from the Town of Queensbury if it does not meet the requirements for placement.
✓Print Name: (Owner,A)t' I ent or Contractor) Date:
9
✓Signature: Date:
✓Signature:
Date:
Town of Queensbury Code Enforcement Officer
1
Town of Queensbury Building&Codes Mobile Home Outside Mobile Home Park Application July 2014
Office Use Only
TOWN BOARD APPLICATION Received
MOBILE HOME OUTSIDE MOBILE HOME PARK Tax Map ID
1- � 1^ I 13 ,
����j Permit No.
DATE' Y ) I C, o Permit Fee
TAx MAP ID 3d�- 17 - i - I
PROPERTY LOCATION: ��o
NAME OF MOBILE HOME PARK: ' 0
PROPOSED DATE OF PLACEMENT:
1
APPLICANT cc Vt �� OWNER C- I �}.� �)VI G"!C
ADDRESS oC�d �Ca Y K 1 I C�� ADDRESS 5 V�J C�I�CI�C� �� C���
PHONE I LS LA3" 5LO5� PHONE (
CONTACT PERSON FOR BUILDING&CODE COMPLIANCE: _ �..-1 t M4 7(au\pin I PHONE: C�
MOBILE Hogg INFORMATION
New Home or Replacement: Year
Singlewide or Doublewide Make
Size of Mobile Home 5 u, ft. x v , , ft. /4y_r Model 977 l 1-1`3
Approximate Value of Home � �� C�(� Serial#
State fully the reasons for this request:
DECLARATION: I swear that to the best of my knowledge and belief the statements containing in this application,together with the
plans and specifications submitted,are a true and complete statement of all proposed work to be done on the described premises
and that all provisions of the Building Code, the Zoning Ordinance, and all other laws pertaining to the proposed work shall be
completed with,whether specified or not, and that such work is authorized by the owner
✓Print Name: I Owner,Agent,Contractor Date:
✓Signature: Date:
c
DECLARATION: I swear that the used mobile home that will be transported into the Town of Queensbury for placement will have
the following:
a) A building permit approved and issued
b) Meet all zoning requirements
c) Mobile Home's HUD sticker affixed to the mobile home
d) Meet HUD requirements for the Middle Zone
As the person responsible for the transport and placement of the mobile home, I accept total responsibility for removal of the
mobile home from the Town of Queensbury if it does not meet the requirements for placement.
✓Print Name: CI l
t`I I►'\ (Owner,Agent or Contractor) Date:
-,'Signature: Dater
✓Signature: Date:
Town of Queensbury Code Enforcement Officer
1
Town of Queensbury Building&Codes Mobile Home Outside Mobile Home Park Application July 2014
SEPTIC DISPOSAL PERMIT APPLICATION office Use Oniv
«. 742 Bay Road,Queensbury,NY 12804
hnm nt(Zmcm burr
P:518-I63.-8256 wvrw.aueensbury.net Permit#:
Tax Map ID#oJ� o a �2-` -� Permit Fee: $ ; invoice#:
Project Location: / Septic Variance? Yes No
Primary Owner(s)
Mailing Address G
Phone & Email 5 IC6-
Installer/Builder
XUA
Mailing Address
Phone & Email
I
Engineer
Mailing Address
Phone & Email VUNI OF QUEENSBURY
BUILDING &
Contact Person for Building&Code Compliance: :�> ` Cr r1d
Phoned
RESIDENCE INFORMATION:
Year Built #of bedrooms X gallons per bedroom =total daily flow Garbage Grinder Yes No
1980 or older installed? (circle one)
1981-1991 Spa or Hot Tub Yes No ,
Installed? (circle one)
1992-Present
PARCEL INFORMATION:
Topography Flat Rolling Steep Slope %Slope
Soil Nature Sand Loam Clay Other
Groundwater At what depth? N A
Bedrock/Impervious material At what depth? W/ IN
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 engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size 1 Cp 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 l5 ft.; Each Trench 0 ft.
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 and approved.
The installed system must match the septic 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 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. r7
PRINT NAME: ° � r, 1 G11'Y� DATE:
r ` G
SIGNATURE: .....�., _. __.� __ DATE: 2 1 I I I b
Town of CQu"e y Building&Code Enforcement Revised February 2017