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RC-0136-2021 Office Use Only \ MANUFACTURED HOME r Permit#: PERMIT APPLICATION Townn ofQueensbury f 7 Permit Fee:$ arm 742 Bay Road,Queensbury,NY 12804 Rec Fee:$ P:518-761-8256 www.gueensbury.net Invoice#: Flood Zone? Y —Reviewed B . ?l Project Location:��(o 1 Tax Map ID#: oct Name of Park(if applicable): PROJECT INFORMATION: 1. Proposed Date of Placement: Co'2-1 I Z1 2. Approximate Value of Home:$ 1fl . nn 3. Is the home or a REPLACEMENT ? 4. Single-wide or Double-wide ; Size: \VA—_ft.X ft.= ���. total square feet 5. Foundation support(choose one): Size Depth Piers: ,Slab: W� 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,): ;#of bedrooms: `7 :#of bathrooms: 8. Additional heat source? No '�— Yes Choose one,if yes: gas fp_ woodstove_ wood fp 9. Are there any other/existing buildings on the property? No—)L Yes ; Explain: 10. What is the water source? PUBLIC_$,_ PRIVATE WELL 11. What.type of wastewater system is on the parcel? SEWER PRIVATE SEPTIC 12. Do you need a septic permit application? No Yes MANUFACTURED HOME INFORMATION: (INFORMATION FOUND ON THE PLATE OR STICKER LOCATED IN THE HOME): Insignia serial#: � z � Name of Manufacturer. �'s�► ���\��— ���@� Place approval#: - �.�`� Model or component design tion New Home Only): Date of manufacture: — ITEM Manufactured Home Application Revised January 2021 i i CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL • Applicant: Name(s): F Mailing Address, C/S/Z: � © — Cell Phone: (45AS) :: —I�UatT Land Line: � ) Email: • Primary Owner(s): Name(s): 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: Cell Phone: Land Line: Email: "Workers' Comp documentation must be submitted with this application" Contact Person for Compliance in regards to this project: c)t-�Fk\-p 1tJ1c��-.`AC ,hF— Cell Phone: Land Line: � ) Email: 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: F"��'�;i�D f`��L' c i_P ev SIGNATURE: � �'� / G" DATE: Manufactured Home Application Revised January 2021 �r <-- SEPTIC DISPOSAL PERMIT office use Only APPLICATION Permit#: Town dQueens ory $ �g Permit Fee:•7 Invoice#: ��fl 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.gueensbury.net Septic Variance? Y 0- Flood Zone? Y N Wetlands? Y N Reviewed By: Project Location: Tax Map #• Md' ,3 RESIDENCE INFORMATION: Year Built Gallons #of bedrooms: X gallons.per =total daily flow per day bedroom Garbage Grinder Yes No 1980 or older 150 1 Installed? (choose one) E1 ya 1981-1991 130 _ IALM CRE Spa or Hot Tub Yes No --Present 110 Installed? (choose one) ❑ PARCEL INFORMATION: Topography ',Flat Rolling ❑ Steep Slope % Slope Soil Nature P<Sand ❑ Loam ❑ Clay ❑ Other, explain: Groundwater At what depth? Bedrock/Impervio.us material At what depth? Domestic Water Supply Dg Municipal ❑Well ❑Lake (if well or 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/ar:.hitect) PROPOSED SYSTEM INFORMATION: Tank size .JQM gallons (min. size 1,000 gallons, add 250 gallons for each garbage cylinder or spa/hot tub System Absorption field w/#2 stone Total length t(n ft.; Each Trench, ft. Seepage Pit w/#3 stone How many: : Size: Alternative System Bed or other type: f Holding Tank System Total required cayacity? ; tank size # of tanks Septic Aoolication Revised April 2021 CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL • Applicant: Name(s): .DaJF�� ©��1�� C Mailing Address, C/S/Z: Cell Phone: ' Land Line: Email: • Primary Owner(s): Name(s): A�A M Mailing Address, C/S/Z: Cell Phone: Land Line: Email: ,Check if all work will be performed by property owner only • Contractor: Contact Name(s): Contractor Trade: Mailing Address, C/S/Z: Cell Phone: Land Line: 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: RDOM-y mb�4j�_:_ Cell Phone: Land Line: Email: 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.N`PRINT NAME: R�t�RC�� 1 '9 J-IDF— - I'CIATtE =n °DATE Septic Aonlication Revised April 2021 TOWN OF OUEENSBURY 742 Bay Road, Queensbury, NY. 12804-5902 . Septic System Checklist Cab O v\, o nJE Plan to scale ' lk�M�F- Received Deep hole perc test results from engineer/Architect if applicable(Town Approved Engineers and Architects;June 30 to April 15 Town Engineer for unapproved Engineers and Architects) t:� All wells on property and adjacent properties shown -b"'3 � '�'D R\�—Az_ Water line shown Municipal or well 10' separation to any part of system Setback to 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 any waterline V--)O 12 N')j Septic tank to foundation crawl space/slab on grade, grade in crawl space must be above top of septic tank for 0',Separation required (field verification required) 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 \J 0 c3 IF—t-111C a D Seepage pit 150'from well 50'from septic tank Seepage Pits 3-times diameter apart Septic tank and pump stations over 30 gallons 50'from watercourse or wetland distance from bottom of trench or system 24"to bedrock or mottling 36" within 1000' of Lake George 41-eech field 100'from watercourse or wetland Toe of mound or bottom of retaining wall 10'from property line 100'from well 20'from Foundation Provide Engineer/Architect stamp for bed or design systems Department of Health Approval for all mobile home park new systems Flood Plain requirements N 2' above established flood elevation to bottom of system _ V" All tanks anchored or 2' above flood elevation : INVOICE Affordable Plumbing&Heating 1396 Tripoli rd Fort Ann NY 12827 United States Stephen M Degnan Sr steven—degnan65@yahoo.com BILL TO Ron Morehouse Invoice No.: 004 8 Vermont Ave Issue date: Mar 28,2022 Queensbury NY 12834 Due date: Mar 28,2022 United States Payment method: Cash s, QESERtPTiOAI QUAt1TITY UNiT i�iZIGE(S) AlIOUt4 P($) Service 1 1 hour 125.00 125.00 Inspection of furnace at 66 Ohio ave Queensbury NY 12804 Furnace is in good working condition SUBTOTAL $125.00 TAX 7.00%from 125.00 $8.75 TOTAL(USD): $133.75 TOTAL DUE (USD) $133.75