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application p, Office Use Only 2�Z0 j ADDITION/ALTERATION PERMIT Permit#: - --` APPLICATION Permit Fee: $ Town of Queensbory 2 742 Bay Road,Queensbury,NY 12804 Invoice#: P:518-761-8256 www.gueensbury.net Project Location: i��Z!�/u i ��ip. Tax Map ID Z Subdivision Name: 1141wc"li CONTACT INFORMATION: • Applicant: j ) Name(s): ©l �✓/�a'115 � r�cT�c►,�r�� � ?'ArJild oel� Mailing Address, C/S/Z: ,1 �'i � �� v s�i✓ Ali���> Cell Phone: � ) j �- 7 Land Line: �) Email: COY-1 � 'UE2 1,0 66,eo Owl • Primary Owners : Name(s): v �,3%/ k Mailing Address, C/S/Z: r/s�Selkd �,rd7"E7 �JVDL ���ti�������f��''. ��•� ��v'� Cell Phone: Land Line: � ) Email: ❑ Check if all work will be performed by homeowner only • Contractor(s): Workers' Comp documentation must be submitted with this application Contact Name(s): �U Contractor Trade: Mailing Address, C/S/Z: Cell Phone: ) Jul--,?966 Land Line: � ) Email: d r,' Olio®�Go "List a I addi ional contractors on the back of this form • Architect(s)/Engineer(s): Business Name: Contact Name(s): 1?1AJ N Mailing Address, C/S/Z: A�� Cell Phone: ( 519 Land Line: �) Email: Contact Person for Building & Code Compliance:� iy Cell Phone: c� (� ) `�c�'/����rr Land Line: �) Email: y- vb1 `.� eco,!461 kco,-f-© 1 1 Addition/Alteration Application Revised February 2019 PROJECT INFORMATION: TYPE: Commercial Residential WORK CLASS: Single-Family _Two-Family _Multi-Family (#of units ) Townhouse Business Office Retail Industrial/Warehouse _Garage (#of cars ) _Other (describe ) ADDITION SQUARE FOOTAGE: ALTERATION SQUARE FOOTAGE: 1st floor: 1st floor: 211 floor: 211 floor: 3rd floor: 311 floor: Basement (habitable space): Basement (habitable space): Total square feet: (C Total square feet: ADDITIONAL PROJECT INFORMATION 1. Estimated Cost of Construction: $ a-o0 2. If Commercial project, what is the proposed use: 3. Source of Heat (circle one): Gas Oil Propane Solar Other Fireplaces need a separate Fuel Burning Appliances & Chimney Application 4. Are there any structures not shown on the plot plan? YES NO� xpIain: 5. Are there any easements on the property? YES NO 6. SITE INFORMATION: a. What is the dimensions or acreage of the rcel? b. Is this a corner lot? YES NO c. Will the grade be changed as a res a construction? YES d. What is the water source? PUBLIC PRIVATE ELL e. Is the parcel on SEWER or a PRIVAT PTIC system? 3c'07-le Addition/Alteration Application Revised February 2019 DECLARATION: 1. 1 acknowledge that no construction shall be commenced prior to issuance of a valid permit and 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 approval. 3. 1 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. 1 acknowledge that prior to occupying the facilities proposed 1, 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 prior to issuance of a certificate of occupancy. I have read and agree to the above: PRINT NAME: SIGNATURE: DATE: Addition/Alteration Application Revised February 2019 is___.mil'• Office Use Only -© - 2Q1L.0 SEPTIC DISPOSAL PERMIT APPLICATION Permit#: RC A'2.11 Permit Fee: $ 1-5 ; Invoice#: Town ofec bury Septic Variance? Yes No 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.gueensbury.net Tax Map ID#: '/ Project Location: lYMI),D•9-dri POI/Vr�WaD • Applicant: / /1 Name(s): 12o,v cJ,941 o s b f-( (moo/L��r2 dG j i a ri Mailing Address, C/S/Z: 1-79 11.1wel- ' Sf- 141->roN Cell Phone: _(��� ) -7k(-S5(.(10 Land Line: _( ) Email: �(-a h { c a poi koo . • Primary Owner(s): Name(s): Q06,62 i vL '%�ey e2! Ai Mailing Address, C/S/Z: h1lP 1r4-A)sB0et7'. A.Y) i9SoLY Cell Phone: Land Line: Email: ❑ Check if all work will be performed by homeowner only • Contractor: Workers' Comp documentation must be submitted with this application Contact Name(s): 6P 14 �iLJGT one P�2�yiylyl,�,�u—a���c� ZL( Contractor Trade: ��s,�s; ✓aT,a ti Mailing Address C/S/Z: 1�;2q Cell Phone: _( Wig )17e l- Land Line: Email:__ 1-otr1 1 i ED— Uca lioo , Co w, L)Q• Eneineer(s): Name(s): Mailing Address, C/S/Z: Cell Phone: _( ) Land Line: _( ) Email: Contact Person for Building & Code Compliance: � rU �/i�92✓i� CelI Phone: _(40 ) 7k/- b (1 Land Line: _( ) Email: ua k o 0 .C-C)✓►, Septic Application Revised February 2019 Y RESIDENCE INFORMATION: Year Built Gallons #of bedrooms: X gallons per =total daily flow per day bedroom Garbage Grinder Yes o 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 _Loam _Clay _Other(explain: ) Groundwater At what depth? Bedrock/Impervious material At what depth? 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: �� //7'r�j e&IA-P LAw�' Tank size /, OO 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 23 ft.; Each Trench 5�r� 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 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: /V V�/ S DATE: Ia o�l Joao SIGNATURE: DATE: Septic Application Revised February2019