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RC-0095-2021 Office Use Only MANUFACTURED HOME Permit#: ?.el`' 00` b" 2021 PERMIT APPLICATION r Town ofQueensbury Permit Fee:$ �1��• 2� 742 Bay Road,Queensbury,NY 12804 Rec Fee:$ NI tv P:518-761-8256 www.gueensbury.net Invoice#: Flood Zone? Y Reviewed By: Project Location: ✓l1 %`U`e- Tax Map ID#: J�� ®9 r. 1 Name of Park(if applicable): PROJECT INFORMATION: MAR q rLUZ .. 1. Proposed Date of.Placement: �1 l 1 L-C;L 2. Approximate Value of Home:$ L, �� TOWN OF Qi liv,SR JR� �/ BUILDIN a-;:i:) :1=5 x 3. Is the home NEW . or a REPLACEMENT ? -""��"""' a 4. Single-wide or Double-wide ; Size: �LLft.X� 'ft._ QQ total square feet 5. Foundation support(choose one): Size Depth Piers: Slab: 6. Is the home being placed on a private lot? No Yes** (**if yes,you must provide stamped engineered drawings of the permanent foundation plan) 7. Total#of rooms(exclude bathrooms): 5 #of bedrooms: 02 ;#of bathrooms: 8. Additional heat source? No_,X_ Yes Choose one, if yes: gas fp_ woodstove_ wood fp 9. Are there any other/existing buildings on the property? No )� Yes ; Explain: 10. What is the water source? PUBLIC_ PRIVATE WELL 11. What type of wastewater system is on-the parcel? SEWER PRIVATE SEPTICA_ 12. Do you need a septic permit application? No Yes See MANUFACTURED HOME INFORMATION: (INFORMATION FOUND ON THE PLATE OR STICKER LOCATED IN THE HOME): Insignia serial #: 1ga CJb17_ �-� (�� -���a`► Name of Manufacturer: ck cra(N A� �� Place approval #: Model or component designation (New Home Only): �4W Y X-S -� -35 Jcln{Zc Ma (1 Date of manufacture: �9- a)q \ Manufactured Home Application Revised January 2021 REQUIREMENTS FOR SUBMITTAL: 1. Completed Manufactured Home permit application THREE (3) COPIES OF THE FOLLOWING: 2. Structural drawings, which include: a. Floor plan b. Foundation plan (see 2015 IRC Appendix E Section AE502:foundation systems) C. If the home is being placed on a private parcel (not in a manufactured home park or designated zone), you MUST provide stamped engineered drawings of the permanent foundation plan. 3. Plot plan, using a survey map if possible, which includes: a. Drawn to scale (i.e. 1 inch =30 feet) b. Indicate proposed location, with setbacks c. Include all structures on the property d. Include location of water supply(well or water lines) e. Include location & configuration of septic system or sewer line ADDITIONAL SUBMITTAL INFORMATION: 1. Installer Warranty seal must be provided prior to issuing Certificate of Occupancy. 2. Any changes to the approved plans prior to or during construction will require the submittal of amended plans, additional reviews and re-approval. 3. If, for any reason,the building permit application is withdrawn, 30% of the fee is retained by the Town of Queensbury. After 1 year from the initial application date, 100% of the fee is retained. 4. Workers' Comp insurance information for all contractors involved—REQUIRED, EVEN FOR SOLE PROPRIETORS 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 complied with,whether specified or not,and that such work is authorized by the owner. I have read and agree to the above: PRINT NAME: - SIGNATURE: DATE: Z Manufactured Home Application Revised January 2021 ° 1 - s CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL • Applicant: Name(s): Mailing Address, C/S/Z: k Cell Phone: Land Line: Email:- ry)o..%. .C 0/1� • Primary Owner(s): Name(s): 1:�ILC_ �'l�� �✓� Mailing Address, C/S/Z: Cell Phone: Land Line: Email: ❑ Check if all work will be performed by the property owner only • Contractor(s): (List all additional contractors on the back of this form) Contact Name(s); Contractor Trade: Mailing Address, C/S/Z:�,D 3Y Cell Phone:_�) Lan d Line: (�ik- ) 3 -�� Email: �**Workers' Comp documentation must be submitted with this application** Contact Person for Compliance in regards to this project: ('IV-Lyq Cell Phone:Phone: _�) Land Line: 5k ) 49 3 2-- Email: ('jutk. -eo k 0'i(2h��-- Manufactured Home Application Revised January 2021 SEPTIC DISPOSAL PERMIT Office use Only APPLICATION Permit#: Town of Queensbury Permit Fee: $ Invoice#: 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.gUeensbury.net Flood Zone? Y N Reviewed By: Project Location: Tax Map M F Ck RESIDENCE INFORMATION: Year Built Gallons #of bedrooms: X gallons per =total daily flow per day bedroom Garbage Grinder Yes N 1980 or older 150 installed? (choose one) 1981-1991 130 Spa or Hot Tub Yes No 1992-Present 110 a�Q Installed? (choose one) 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 t6to—rl)ake, nicipalWell Lake water supply from any septic system absorption is ft.) Percolation Test Rate:, per minute per inch (test to be completed by a licensed engineer/architect) PROPOSED SYSTEM INFORMATION: Tank size ADD allons (min. size 1,000 gallons, add 250 gallons for each garbage cylinder or spa/hot tub System Absorption field w/#2 stone Total length \`&D ft.; Each Trench (Jb ft. ya Seepage Pit w/#3 stone How many: ; Size: Alternative System Bed or other type: Holding Tank System Total required capacity? ; tank size ; # of tanks Septic Application Revised January 2021 CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL • A licant: Mailing Address, C/S/Z: c��chn,� � �-t Cell Phone: Land Line: Email:• Primary Owner(s): Name(s): `JDV__c_ qoIGQ vv, \ernc Mailing Address, C/S/Z: �,9 +�,oVLr, N�xC QVDA �J\� i2 � Cell Phone: Land Line: Email: Check if all work will be performed by property owner only • Contractor•.Contact Name(s): Clw �r�-ier,��ri SAS Lnc Contractor Trade: U Mailing Address, C/S/Z: �- Cell Phone: Land Line:-1Q,3 --- Email: "Workers' Comp documentation must be submitted with this application" • Engineer(s)• Name(s): Mailing Address, C/S/Z: -Cell Phone: Land Line: Email: Contact Person for Compliance in regards to this project: L Lk Cell Phone: Land Line: Email: C44ef-\4 (4!,r@d M&,( •cam-• 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. 4. If, for any reason, the building permit application is withdrawn, 30% of the fee is retained by the Town of Queensbury. After 1 year from the initial application date, 100, of the fee is retained. 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: Lo-m U. SIGNATURE: DATE: Septic Application Revised January 2021 TOM TOMW OJT` ®UEENSB RY 742 Bay Road, Queensbury, NY. 12804-5902 SepticSystem Checklist Plan to scale Received Deep hole pert test results from engineer/Architect if a.pplica.ble(Town Approved IE *heers and Architects)(llma a.30 to Aprr6l 15 Town Eruginger for unapproved En.gi peers and Arrch�teds) All wells on property and adjacent properties shown Water line shown Municipal or well 10'separation to any part of system ISetbackto property lines show 10'or more for any part of system %Septic tank and pump stations 10'from foundation 50'from any well/lake/wetland 10'from,a.ny waterline 4 Septic tank to foundation crawl space/slab n rade,grade in crawl space most be above top of septic tank for 0',Separation required (field verification required) /v MvVr I r�� 0 Septic tank sized for number of bedrooms and add 250 gals for Jacuzzi tubs/garbage,grinder-each Leech Field 20'from foundation 100'from any well 10'from water line KII'�Seepage Pit 150'from well 50'from septic tank NIA—Seepage Pits 3-times diameter apart i65-Septic tank and pump stations over 30 gallons SU from watercourse or wetland N4 distance from bottom of trench or system 24"to bedrock or mottling 36"within 1000'of lake george ` Leech field 100'from watercourse or wetland Mk Toe of mound or bottom of'retaining-wall 10'from property line 100'from well 20'ftom Foundation Provide Engineer/Architect stamp for bed,or design systems M4 Department of Health Approval for all mobile home park new systems Flood Plaun requ6rements k2'above established flood elevation to bottom of system LAIJ tanksanchored or 2' above.flood elevation 12— �/� " " Home of Natural Be;auty ... A Good Place to Live " S 83.1 10 0" E 1Pf ANCHORING OP It ate TOWN ®F MOBILE HOME _ 1\� BUILDING QUEENSSDRY' FRAME IS REQUIRED PER BNG &.C®® S-DEPTo MANUFACTURERS SPECIFICATIONS Reviewed i'' ti'd�`vtl•A` ^a� t10,50 Date: - ��_ • 3 I � ?' ends r; v ^' ands;. L L N Go America �.LC ,3 0. 6 di B:5977 p:87 r DKC .NO Og.9-I -97 n 13-0077 3 TOWN OF QUEENSBURY3 , Are g BUILDING DEPARTMENT QSpp p t Fee I Based on our limited examination;com lance p.1 p; Acres I a with our comments shall not,be construed-, s indicating the plans and spec�ficatibns are in o full compliance with the -Building:Codes".>of F-:I:LE C=OP Y e New York State. o rrr%ti � I N 31 10' 10" IV C' iiitral AV enu 1 Deed References Priscilla E.tEddy, Er. AL, 309.9-1-58 RC-0095-2021 DKC Holding, Inc. DKC Holdings D E c' Dated October 31, 2018 In Book 5451 Page 175 Rt John W. Eldred and 0'�Central Ave Deborah J. Eldred New Manufactured Home 693 s.f. CR, MAR 0 5 � 2� TO Lands NIF e Barbara J. Mallaney John E. Daly -----T— -- ---—— --_-- ----' Dated: January 25, 1997 19:2968 P:278 Recorded on: January 27, 1997 309.9-1-5G P:181 NIF of 1A1N OF TO B:1009 Michael Salley V VV'V f QUEEIVSBURY S:1D22 P:166 BUILDING& CODES 309.9.1.44 41 8 1?3 010.E 9 Angle Ircn 50.00. r•� d CRP �"1 loao ' 3 Lands NIF of Go America LLC B:5977 5 c O 309.9.1-7 5 0 Lands NIF of Ty Are I DKC Holding, Inc. .Ly 4500 Os Fe B:4077 P:46 rc as ' 309.9-1-43 uu9 o co a $ r IPP On�a�=7OI W (�"1 ®IPF '. r'' I'al iZ V'enul NOTe5: ....._.:.:.:`:; :!..:...":., •:".. .:�, :.....,'.', ":',' .:•..v;'� MI5 MAP WAS PREPARED WiTNOUT THE BENEFIT Of MI AETSTRACi OP TIRE OR AN UP TO DATE TITLE REPORT AND I9 THEREFORE SUBJECT TO U.P.NTfl9 .. '.1 -:;...,:-,:';.,• ,.•.:...::::....:::..... ..::..::.';;`•• row11 THEREON.ANY STATEMENT 0P rACTs s TO ANY EaSeMeNrs or RECORD. 2.) PARCEL IS SUBJECT 3.) THO MAP WA5 PREPARED FROM AN ACTUAL FIELD 5URVEY MADE IN u P.wn,a ACCORDANCE WITN THL't1(15TOlG COD[OF FRACTICC PDDITED BY THE NEW YORC 5TATE A550CIATION OF PROFE55IONAL LAND 5URVEYOPS. 4.) THIS MAP 15 COPYRIGHT©2018 VAN DUSEN 4 5TEVE5 LAND 5URVCYOR5.UNAUTHORIZED ALTERATION OR ADDITION TO THI5 Legend DOCUMENT 15 VIOLATION OF 5ECTION 7209.5UDDIVI5ION 2,OF NEW YOM 5TATE EDUCATION LAW. ZPF=iron Pipe Found 5.1 DIMENSIONS FOOTBETWEENA PROPERTY UNCS AND STRUCTURES ARE TO THE CIRF= Capped Iron Rod Found � NEAREST HALT MOOT AND ARE FOR THE 50LY PURP055 Or "o+U.P. =Utility Pale IMeRFRETINGTHEIRcONFORMANCEWITH ZONING AND NOT INTENDED — - - —=Overhead Utility V11re TO AID IN THE E5TABL15HMENT OR RETRACPMENT OF PROPERTY UNE5, G.) UNDERGROUND UTILITIES,IF ANY,ARE NOT SHOWN HEREON. Date: ct0 eT 01, 201 'v `dn Du S e v-� .6TM Plot Plan made for Scale 1'=20' St.eves S-1 Land Surveyors DKC Holding, Inc. 2 12123120 REVISED PLOT PLAN SHEET IOF 1 169 Naviland Road Queensbur New York 12804 K.,� ,.,n . Town of Queensbury, Warren County, New York Y� 1 03/05/19 RECORD OF RESOLUTION ADDED DNc nue�,y,Ina. (518) 792-8474 New York Lic. No. 50135 NO. DATE DESCRIPTION DWG.NO.ID-155 C3.19 309.9-I-`vD 64252 NAME SHIP TO .i ADDRE ADDRESS 4�t CITY,KE,ZIPc � � CITY,STATE,ZIP J Cd AS�c�- - ORDER NO. TERMS DATE WHEN SHIP HOW SHIP SALESPERSON QUANTITY DESCRIPTION PRICE AMOUNT ti AR 17 2021 T VVN OF I UILDIRIG& CODES BUYER A- T-46500/46610 KEEP THIa SLIP FOR REFERENCE 50