applications LEVr4ice
Use Only
mitt#: RC- 02-3Z-- ' 2vl4'
PRINCIPLE • T UU R T
AP LIC P rmit Fee:$ 32-7. 6&
of Clgeens'buiy TOWN OFQUEENSBURY ec Fee:$ (6- G •UO
742 Bay Road,Queensbury,NY 12804 BUY LDai G&COI;ES *
P:518-761-8256 www.queensbury.net Invoice#: 03j(�r
7
Project Location: ICI a r Ctr.,
Tax Map ID#: 3 0 \— Subdivision Name:
*TOWN BD.RESOLUTION 86-2013: $850 recreation fee for new dwelling units: single family,duplexes/two-family,
multiple family, apartments, condominiums,townhouses, and/or manufactured & modular homes, but not mobile
homes. This Is In addition to the permit fee(s).
CONTACT INFORMATION:
• Applicant: •
Name(s): rC
Mailing Address,C/S/Z:
Cell Phone: ( ) Land Line: ( )
Email:
• Primary Owner(s):
Name(s): C \ �\
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: ( )
Email:
• Contractor(s):
Business Name: C
Contact Name(s): 1,._..Cc,17-1
Mailing Address, C/S/Z: Cen
�\�,e �_ ��
Cell Phone: ( ) Land Line: (Slw) `Z�z `7:�ez'7
Email: c' \j-k-e_e ' -c1 \ C •
• Architect(s)/Engineer(s):
Business Name:
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: ( )
Email:
Contact Person for Building& Code Compliance: Y
Cell Phone: ( Land Line: ( )
Email:
•
Town of Queensbury Building&Code Enforcement Principle Structure Application Revised February 2017
yd m .
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•
PROJECT INFORMATION:
TYPE: Commercial X/ Residential
WORK CLASS:
Single-Family Two-Family Multi-Family(#of )
Townhouse Business Office Retail Hotel/Motel
Industrial/Warehouse Garage(#ofcars ) Other(describe )
STRUCTURE SQUARE FOOTAGE: GARAGE SQUARE FOOTAGE:
sr `
isT floor: \c)9 1 flo :
2nd floor: 2nd floor:
3rd floor: Total are feet:
4th floor:
Total square feet: \.09 -
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ 21 ceND
2. Proposed use of the building: ` - T6Zp
3. If Commercial or Industrial, indicate the name of the business:
4. Source of Heat(circle one):11101110il Propane Solar Other:
(Fireplaces need a separate Fue : • : Appliances&Chimney Application, one per appliance)
. 5. Are there any structures not shown on the plot plan? YES NO slain:
6. Are there any easements on the property? YES NO
• 7. SITE INFORMATION:
a. What is the dimensions or acreage arcel? 2.0
b. Is this a corner lot? YES NO
c. Will the grade be changed as a result of the construction? YES O
d.What is the water source? RLLBJ IC PRIVATE 111MIP
e. Is the parcel on SEWER PRIVATE SEPTIC syste ?
fkci-P\
Town of Oueenstoury Building&Code Enforcement Principle Structure Apptaton Revised February 201i
4
DECLARATION;
ION+
I. € acknowledge that no construction shall commence prior to issuance of a valid building permit and
work will be completed within a 12 month period. 1
2. lfthework is not completed by the 1 year expiration date the permit may be renewed, subject to
fees and department approval.
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. 1 also 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.
l have read and agree to the above:
PRINT NAME:
SIGNATURE: DATE: 617 I\7—
Town of Queensbury Building&Code Enforcement • Principle Structure Application Revised February 2017
47.4
i' SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
-- 742 Bay Road,Queensbury,NY 12804
Town ofQucensbury P:518-761-8256 www.queensburv.net Permit#:
Tax Map ID#: c1® 1-7— 1— 2 o> Permit Fee:$ ; Invoice#:
Project Location: "-k-dioCaS Septic Variance? Yes No
Primary Owner(s) �� r �� 3
Mailing Address
Phone & Email
Installer/Builder / C13k Fr-7 -
Mailing Address Cte7 c
Phone & Email
Engineer
Mailing Address
Phone & Email
Contact Person for Building&Code Compliance: 7- — Phone: ( Z f®
RESIDENCE INFORMATION: I
Year Built Gallons #of bedrooms X gallons per =total daily flow
per day bedroom Garbage Grinder Yes No
1980 or older 150 Installed? (circle one)
1981-1991 130 Spa or Hot Tub Yes CI o
Installed? (circle one)
1992-Present 110 t
PARCEL INFORMATION:
Topography Flat Rolling Steep Slope %Slope
Soil Nature and Loam Clay Other
Groundwater At what depth?
Bedrock/Impervious material At what depth?
Domestic Water Supply —Municipal ell (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 `DCOgallons(min. size 1,000 gallons, add 250 gallons for each garbage cylinder or spa/hot tub
System Absorption field with#2 stone Total length (5c.Q ft.; Each Trench 5 D 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.
PRINT NAME: C— DATE:
SIGNATURE: / DATE: �lL�o�Li
Town of Queensbury Buil ng ode Enforcement" Revised March 2018