applications Office Use Only
MANUFACTURED HOME Permit#: QC'(91+9�Q - 2020
PERMIT APPLICATION Permit Fee: $
TO of Queensbury
742 Bay Road,Queensbury,NY 12804
Rec Fee: $
P:518-761-8256 www.aueensbury.net
Invoice#: JZ.S�
Project Location: ll�� —111(�(�I S �l�l(J�-2- Tax Map ID#:�� l i —
Name of Park: Y) Proposed Date of Placement:
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CONTACT INFORMATION: '
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• Applicant: �a DEC 2 Z 2020
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Name(s): L' A-I&Cyk2!P4 i `Ac - . T(1!AINI 017 01 Efr N€S"`:f IPY' 1
Mailing Address, C/S/Z: j i2P4i lV-)�''"-�-1
Cell Phone: _�) Land Line: ( 5\6-
Em a i I: 1M ` c_rJv�•
• Primary Owners :
Name(s):
Mailing Address, C/S/Z:
Cell Phone: Land Line: �)
Email:
❑ Check if all work will be performed by homeowner only
• Contractor(s): 1�
Contact Name(s): a, U--� C� L .
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: Land Line: (161V ) t3 �--��-
Email• C, `
"List all additional con rectors on the back of this form
Contact Person for Building & Code Compliance: (�
Cell Phone: Land Lind-
Email:
Manufactured Home Application Revised February 2019
MANUFACTURED HOME INFORMATION:
(INFORMATION FOUND ON THE PLATE OR STICKER LOCATED IN THE HOME):,
Insignia serial#: 1r �r�c — ���� � 1 "��� E5b _9 /►�
Name of Manufacturer: �yl�,P S
Place approval#:
Model or component designation (New Home Only): F-1ol4'z` T_� \f--^ 'PCs -aa-l-04161. &
Date of manufacture: e92ff
ADDITIONAL INFORMATION:
,
1. Approximate Value of Home:$ 6�Z 9/�
2. Is the home NEW)�_3 or a REPLACEMENT ?
3. Single-wide� or Double-wide Size: 13 ft.X ft.
4. Foundation support(choose one): Size Depth
_Piers:
kk
5. Is the home being placed on a private lot? No Yes (if yes,you srovi a seam a in
drawings of the permanent foundation plan)
6. Total#of rooms(exclude bathrooms): ;#of bedrooms: ;#of bathrooms: -�---
7. Additional heat source? No Yes Choose one, if yes: gas fp_ woodstove_ wood fp
S. Are there any other/existing buildings on the property? No�)6' Yes ; Explain:
9. What is the water source? PUBLIC PRIVATE WELL
10. Is the parcel on SEWER or a PRIVATE SEPTIC system?
11. Do you need a septic permit application? No Yes
DECLARATION:
I swear that,to the best of my knowledge and belief,the statements contained 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 NYS Building Code,the Zoning Ordinance and all other laws pertaining to the
proposed work shall be completed with
I have read and agree to the above:
PRINT NAME:
SIGNATURE: DATE:
Manufactured Home Application Revised February 2019
Office Use Only
SEPTIC DISPOSAL PERMIT APPLICATION Permit#:
Permit Fee: $ invoice#:
Town otqueensbury Septic Variance? Yes ✓ No
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.gueensbury.net
Tax Map ID#: '"► 1 1
Project Location: ---WNUC-:S
• Applicant:
Name(s): S \mac _
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line:
Email:_
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• Primary Owner(s):
Name(s):
Mailing Address, C/S/Z: \ Q ► Qolwt� MY ?
Cell Phone:_( ) Land Line: _( _) 2, 3'��-�-
Emai1: Ut (�./):kr JGC,7& � . (ram
❑ Check if all work will be performed by homeowner only
• Contractor: Workers' Comp documentation must be submitted with this application
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: _( ) Land
Email: f .,.
• ig
Engineer(s)•
Name(s): s K
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line:
• ., ..
Email: 4; ` 6
Contact Person for Building & Code Compliance: Lo,-M6 Gl`�
Cell Phone: _(_ -6-) 3U 1 �,� Land Line: _(1 V —qek )j
Email: .�. �-e te e. ���s v�--�.`f t
Septic Application Revised February 2019
A-
RESIDENCE INFORMATION:
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 o
Installed? (circle one)
1992-Present 110
PARCEL INFORMATION:
Topography Flat Rolling Steep Slope %Slope
Soil Nature Sand _Lo m _Clay _Other(explain: )
Groundwater At what depth? IN
Bedrock/Impervious material At what depth? A A
Domestic Water Supply unicip I _Well (if well,water supply from any septic system absorption is ft.)
Percolation Test Rate: C=6 per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size /bDOgallons (min.size 1,000 gallons, add 250 gallons for each garbage cylinder or spa/hot tub
System Absorption field with#2 stone Total length ft.; Each Trench��Jo 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: L 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� - DATE:
SIGNATURE: DATE:
Septic Application Revised February 2019