2005-510 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development - Building & Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20050510 Date Issued: Wednesday, August 03, 2005
This is to certify that work requested to be done as shown by Permit Number P20050510
has been completed.
Tax Map Number: 523400-302-018-0003-030-000-0000
Location: 16 BROADACRES Rd
Owner: JEFFREY& AMY COLLINS
Applicant: AMY & JEFFREY COLLINS
This structure may be occupied as a:
Septic Alteration Residential
By Order of Town Board
TOWN OF QUEENSBURY
Issuance of this Certificate of Compliance DOES NOT relieve the
property owner of the responsibility for compliance with Site Plan,
Variance, or other issues and conditions as a result of approvals by the Director of Building&Code Enforcement
Planning Board or Zoning Board of Appeals.
TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20050510 Application Number: A20050510
Tat T\-lap No: 523400-302-018-0003-030-000-0000
Permission is hereby granted to: AMY& TF,FFRF.Y COLLINS
For property located at: 16 BROADACRES Rd
in the Town of Queensbury,to construct or place
at the above location in accordance with application together with plot plans and other information hereto filed
and approved and in compliance with the NYS Uniform Building Codes and the Queensbury Zoning
Ordinance. Type of Construction Value
Owner Address: SANDRA L BUCHMAN
16 BROADACRES Rd Septic Alteration Residential
Total Value
QUEENSBURY, NY 12804
Contractor or Builder's Name /Address Electrical Inspection Agency
Ol TEENSB1 TRY SEWER
JAY SWEET
Plans&Specifications
2005-510
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Tuesday, July 11, 2006
(if a longer period is required,an application for an extension must be made to the code Enforcement Officer
of the Town of Queensbury before the expiration date.)
Dated at the Town of Queensbury; Monday, July 11, 2005
SIGNED BY //J for the Town of Queensbury.
irector of Buildi o Enforcement
Application for Permit-Septic Disposal System
Town of Queensbury 742 Bay Road Queensbury,NY 12804 (518) 761-8256
1. OWNER INFORMATION: :......................................................................................................................................:
Office Use
Location of installation: l ty4o jjx,;t,ir QJcu-f/�v �/
File Permit No.
Tax Map No.
��l< < ; Fee Paid j
Owner's Name: Amv if
Address: �G f14.-/F , *,� &d j zt4 f s < , A'y Q 6e To"A 3-3,
2. INSTALLER'S NAMEPHONE:
3. RESIDENCE INFORMATION: (circle year of dwelling, indicate#bedroom(s) and multiply #of
bedrooms with applicable gallons per bedroom to equal total daily flow)
Year of House: No. of Bedrooms x Computation = Total Daily Flow
1980 er x 150 ga1/bdrm = _
1980— 1991 x 130 gal/bdrm =
1991 —present x 110 gal/bdrm =
Garbage Grinder Installed yes_ L. { - 1 D5
Spa or Hot Tub Installed yes 4 /ci4 TOWN OF 00LENSgURY
BUILDING AND CODE
4. PARCEL INFORMATION: (circle applicable information&indicate measurements)
ToDozranhv Soil Nature Ground Water Bedrock or Impervious Material Domestic Water So ply
at what depth at what depth munici a
olling loam feet feet well
Steep slope clay if well; water supply
�%slope other from any septic-system
depth: absorption is ft.
other
Percolation Test: (To be completed by licensed professional engineer or architect)
Rate: minute per inch
5. PROPOSED SYSTEM: For New Construction: All individual sewage disposal systems must be designed by a licensed
professional engineer or architect(unless installed in a Planning Board approved subdivision). Add 250 gallons to the size
of the septic tank and leach field for each Garbage Grinder,Spa or Whirlpool Tub.
Septic Tank:
gR:r_L gallon (min. size 1,000 gal)
kA4t I -trr'-k-/ws
--Lk-Field: each trench Total System Length:
Seepage Pit(s): number of size of each: ft. by ft.
Size of Stone to be used: # / depth or thickness feet
Bed System Size: x
Alternative System: length and/or size
6. HOLDING TANK SYSTEM: (if required)
Number of tanks: / Size of each: gallons /TOTAL Capacity: gallons
Note: Alarm System and associated electrical work must be inspected by a Town approved
electrical inspection agency.
7. SIGNATURE &INFORMATION FOR RESPONSIBLE PERSON(please read)
For your protection,please note that pursuant to Section 136-29 of the Code of the Town
of Queensbury,any permit or approval granted which is based upon or is granted in
reliance upon any material misrepresentation 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 with respect to this application and agree to abide by these and all
requirements of the Town of Queensbury Sanitary Sewage Disposal Ordinance.
U
Z-
Skjn re f responsible erson Date
Town of Qum& Building & Code Enforcement
Office No. (518) 761-8256
Septic Inspection Report
Inspection request received:
Name: C � Inspected on: 7 L4
t
Location: % ( � ./�.��f�C�iCi ' ? J� Arrive: a.m.I P.M.
Permit No.: C% 5- — /C' Inspector's Initials:
Comments and/or diagram
Soil Type: Sand I Loam I Clay
Type of Water: Municipal/Well Water
Waterline separation distance ft.
Well separation distance ft.
Other wells: N ft.
Well Casing Length 50'+/ Y N /A
[150'to well required if NO]
Absorption Field: Total length ft.
Length of each trench
Depth of trenches ft.
Size of Stone
Seepage Pits: Number
Size: x
Stone Size:
Piping Size Type
Building to tank
Tank to Distribution Box
Distribution Box to Field/Pit
Opening Sealed: N
End Cap N
Inlet/Outlet Pipes&Baffles Y N
Manholes 12"or less below gi ade _Y N
[provide extension collar if Ye ] _Y N _��1
Location/Separations
Foundation to tank ft.
Foundation to absorption
Separation of Pits
Conforms as per Plot Plan V Y
Engineer Report and As-Built _Y_N
ETU Maintenance Contract provided _Y_N
Location of System on Property:
Front Re Left Side Rig ide Middle Front Middle Rear
System Use Stat
Appro
ial Approved and needs to be re-inspected, please call the Building&Codes Office
Disapproved
Septic Inspection Report
Septic Inspection Report
Office No. (518)761-8256 Date Inspection request received:
Queensbury Building&Code Enforcement Arrive: am/pr�I r,Depart: p
742 Bay Rd.,Queensbury,NY 12804 Inspector's Initials: V���
NAME: DLL/�� PERMIT NO.:
LOCATION: �.E'0�4b/.�� INSPECT ON:
RECHECK: '
Comments and/or diagram
Soil Type: Sand/Loam/Clay
Type of Water: Municipal/Well Water
Waterline separation distance ft.
Well separation distance
Other wells: $.
Absorption Field: Total length ft.
Length of each trench ft.
D th of trenches ft.
Size of Stone
Seepage Pits: Number
Size: x
Stone Size:
Piping Size Type
Building to tank
Tank to Distrib Box
Distribution B6j td 3eld/Pit
Opening Seale : Y/N/Partial
Location/Separations
Foundation to tank ft.
Foundation to absorption ft.
Separation of Pits ft.
Conforms as per Plot Plan Y N
Location of System on Property:
Front Rear Left Side Right Side
Middle Fro Middle Rear
System Use St
Approved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
L:\SueHemingway\Building.Codes.Inspection.FORMS\Septic Inspection Report.doc January 28,2003
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Septic Inspection Report
1
Office No.(518)761-8256 Date Inspection request received: "�, ./-5
Queensbury Building&Code Enforcement Arrive: am/pp�, epart: am/pm
742 Bay Rd_.,Queensbury,NY 12804 Inspector's Initials: '
NAME• A ��f �LtiL ) Cv(�� 5 PERMIT NO.:
LOCAT
ON: �,� _ �� INSPECT ON: 3
RECHECK:
Comments and/or diagram
Soil Type: San o / la
Type of Wa er: unicipa /Well Water
Waterline separALon d' nce ft.
Well separation distance _ ft.
Other wells: ft.
Absorption Field: Total length ft.
Length of each trench ft.
Depth of trenches ft.
Size of Stone —' L -
See a e Pits: Number
Size: x
Stone Size:
Piping SiZA.. Type
Building to tank L
Tank to Distributio
Distribution Box to rie /Pit
OpeningSealed: Y k&/kartial �-(, 'r�o
End Caps
Location/Separations JA
Foundation to tank ft.
Foundation to abso tion
Separation of Pits ft.
Conforms as per Plot Plan Y N
En sneer Report and As-Built Y N
Location of System on Property:
Front ea Left Side Right Side
Middle ront Middle Rear
System Use Status:
Approved
Partial Approved and needs to be re-inspected, please call the Building&Codes Office
Disapproved
Last revised 1/6/05
Queensbury Building & Code Enforcement - Resi ti al Inspection
Office No.(518)761-8256 Arrive: am/p apart: amt,(
Date Inspection request received: Inspector's Inif is `
NAME: RMIT#: j
LOCATION:
TYPE OF STRUCTURE:
Comments
�
Building Number/Address visible from road Yes No N/A
Chimney Height/"B"Vent/Direct Vent Location 9_, jj
Fresh Air Intake
3 inch Plumbing Vent through roof minimum 6 inches
Roof Complete/Exterior Finish Complete
Platform at all exterior doors
Guards at stairs,decks,patios more than 30 inches above grade
Guard at stairwell at 34 inches or more
Guard at deck,porches 36 inches or more
Handrail Termination at Newell Post or Wall
Interior/Exterior Railings 34 inches to 38 inches
Interior Handrails P,stairs 2 or more risers
Grade away from foundation 6 inches with 10 feet
6 inch clearance to sill plate
Gas Valve shut-off exposed/regulator 18 inches above grade
Interior privacy/trim/doors/main entrance 36 inches
Bathroom/Kitchen watertight
Safeglazing/Window in stairwells safety glazing
Interior Smoke Detectors:
Every level: Every Bedroom:
Outside every bedroom area:---
Inter Connected: Battery backup:
Carbon Monoxide Detector
Attic access 30 inches x 22 inches x 30 inches(height)in accessible area
Crawl Spaces 18 inch x 24 inch access, 1 s .ft,150 s .ft.vents
Bathroom Fans,if no window
Plumbing fixtures
Foundation insulation
Floor truss,draft stopping finished basement 1,000 s .ft.
Emergency egress below grade
Gas Furnace shut-off within 30 feet or within line of site
Oil Furnace shut-off at entrance to furnace area
Furnace/Hot Water Heater operating_
Low water shut-off boiler
Relief Valve(s)installed/Heat Trap/Water Temp 110
Enclosed Stairs Sheetrock Underside minimum%z"Gypsum
Basement stairs closed rise>4 inches
Garage Floor Pitched
Garage fireproofing/3/4 hour fire door/door closer
Duct work Sealed properly
Gas Logs in Sealed or Glass Enclosure
Final Electrical
Final Survey Plot Plan
As Built Septic System/Sewer Dept.Inspection Sticker
Site Plan /Variance required
Flood Plain Certification, ' uired
Okay to issue C/C oK/Ojqe or Permanent
L:\Building&Codes Forms\Building&Codes\Inspection Forms\Residential Final Inspection Form revised 100405.doc
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5 BY THIS CERTIFICATE OF COMPLIANCE THE 0 —'S—` 5
5 NEW YORK BOARD OF FIRE UNDERWRITERS 5
5 S
SBUREAU OF ELECTRICITY 5
5 40 FULTON STREET - NEW YORK, NY 10038 55
5 CERTIFIES THAT S
5 S
SUpon the application of upon premises owned by 5
5 S
5 JEFF
COLLINS JEFF COLLINS
PO BOX 630 S
GLENNS FALLS, NY 12801 GLENS FALLS, NY 12801 5
S 5
5 16 BROADACRES RD QUEENSBURY, TN, NY 12804 5
5 Application Number: 2054542 Certificate Number: 2054542 5
5 5
5 Section: Block: Lot: Building Permit: BDC. A2 39 S
5 5 Described as a Residential occupancy, wherein the premises electrical system consisting of 5
5 electrical devices and wiring, described below, located in/on the premises at: 5
5 Basement,Outside,
5 5
5 A visual inspection of the premises electrical system, limited to electrical devices and wiring to the extent detailed
5 herein, was conducted in accordance with the requirements of the applicable code and/or standard
5 promulgated by the State of New York, Department of State Code Enforcement and Administration, or other S
5 authority having jurisdiction, and found to be in compliance therewith on the 8th Day of September,2006. 5
5 Name (OTY Rate Rating Circuit Tyne
5 Panels 5
5 1 200 40 CU
SService Cj
5 1 Phase 3 W Service Rating 200 Amperes
5 Service Disconnect: 1 200 cb
Meters: l
S 5
S S
S 5
5 S
5 5
5 _ 5
seal
5 _ 5
5 1 of 1 5
5 5
SThis certificate may not be altered in any way and is validated only by the presence of a raised seal at the location indicated. 5
5 5
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