CC-000171-2015 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5904 (518)761.8201
Community Development-Building& Codes (518)761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: CC-000171-2015 Date Issued: Friday, October 28, 2016
This is to certify that work requested to be done as shown by Permit Number CC-000171-2015
has been completed.
Tax Map Number: 308.16-2-2.3
Location: 9 CAREY RD
Owner: HHHN
Applicant: HHHN
This structure may be occupied as a: Comm.Alt.(pipes to septic)
By Order of Toam Board
TOWN OF QUEEN/S�BURY
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 12804-5904 (518)761-8201
OL Community Development-Building&Codes (518)761-8256
BUILDING PERMIT
Permit Number: CC-000171-2015 12Q� �J bql
Tax Map No: 308.16-2-2.3 _T
Permission is hereby granted to: HHHN REVISED
For properly located at: 9 CAREY 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
Owner Name: HHHN Factory-Industrial-Alteration $16,000.00
Owner Address: 9 CAREY RD Total Value $16,000.00
Queensbury,NY 12804
Contractor or Builder's Name/Address Electrical Inspection Agency
Jim McCormick
9 Carey
Queensbury,NY
Plans&Specifications
Comm.Alt.(pipes to septic)
PERMIT FEE PAID-THIS PERMIT EXPIRES: Friday,October 7,2016
(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!
(/Tmw f Queensb //J� es ,October 7,2015
SIGNED Blt: ',v for the Town of Queensbury.
Director of Building&Code Enforcement
TOWN OF QUEENSBURY
A 742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
VW
Community Development-Building& Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20150469 Application Number: A20150469
Tax Map No: 523400-308-016-0002-002-003-0000
Permission is hereby granted to: HUDSON HEADWATERS HEALTH
For property located at: 9 CAREY 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: HUDSON HEADWATERS HEALTH
9 CAREY Rd Commercial Alteration $16,000.00
QUEENSBURY NY 12801-0000 Total Value $16,000.00
Contractor or Builder's Name /Address Electrical Inspection Agency
Plans&Specifications
2015-469
Commercial Alteration
For internal pipes to septic system
$75.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Friday, October 07,2016
(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 th expiration dat-.)
Dated at the T n of ns ry,�f A ,;nesday, October 07,2015
SIGNED BY V \ for the Town of Queensbury.
Director of Building&Code Enforcement
PRINCIPAL STRUCTURE AP - - .
' - � �° ��.:,.. Office Use Only
vLE eceived
Date: 1 O .1.1 S ax Map 1D
2 2 s 2015 ermit No.
Tax Map ID 0 :. tiermit Fee 7�00
Zone T•WN"OF OUEERec Fee
Historic Site Yes ,-�UILDING& CODESN'SBURY Site Plan#
Subdivision Name CARE' r•lpvYri)AL Nu. Lot# Subdivision#
Project Location °I GAYE't KdAD Q.BuRv
TOWN BD. RESOLUTION 86-2013: $850 recreation fee for new dwelling units—single family, duplexes/two-family,
multiple family,apartments, condominiums,townhouses, and/or manufactured &modular homes, but not mobile
homes. This is in addition to the permit fee(s).
Applicant
tkUDSv� E� OwnerviKreg.s SflMC.
Address CRR8‘? R•o p Address
Phone/E-mailS w� C o f�ma �!1 HN.it r6Phone/E-mail
Contact Person for Building&Codes Compliance: 1 f \ M L La>Rrrin L1. Phone$titi• g(o22
TYPE OF CONSTRUCTION
✓Check all that apply New Addition Alteration 1"floor sf 2nd floor sf Total sf Height
Single Family
Two-Family
Multi-Family
(#of units )
Townhouse
Business Office
Retail-Mercantile
Factory-Industrial
Attached Garage
(1, 2, 3, 4+)
Other
If commercial or industrial please indicate of business
Town of Queensbury Building&Codes Principal Structure Application Revised September 2015
Proposed use of building or addition O F(;L�
Source of Heat(circle one) Gag Oil Propane Solar Other
Fireplace: Complete a separate application for Fuel Burning
Appliances& Chimneys k
Are there structures not shown on plot plan? o
Are there easements on the property? o
Site Information
a. Dimensions or acreage of lot 2 .I Cy
b. Is this a corner lot? Y E S
c. Will the grade be changed as a result of construction Yes .c No
d. Public water or Private well Q u isi,;‘
e. Sewer or Private Septic System
Value of all work to be performed(labor or materials) $ ► (o)o 00• a o
DECLARATION:
1. I acknowledge no construction shall be commenced prior to issuance of a valid permit and will be completed
within a 12 month period.
2. If work is not complete by the 1 year expiration date the permit may be renewed, subject to fees and
department approval.
3. I certify that the application,plans and supporting materials are a true and complete statement/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. I acknowledge that prior to occupying the facilities proposed, I or my agents will obtain a certificate of
occupancy.
5. I 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: I Yh 664)12.1)1.)a- DATE: 10/1/ S
SIGNATURE: ill op, A ,.4, DATE:
For office use only
Operating Permit Issued: Yes No
Occupancy Type
Construction Classification
Assembly Occupancy Limit
Special Conditions
Town of Queensbury Building&Codes Principal Structure Application Revised September 2015
CHECKLIST—SINGLE FAMILY PROJECT Project Name:
REQUIRED—2 SETS Yes No N/A
1. Building Permit completed
2. Energy Code inspector's report from REScheck completed
3. Septic alteration
4. Solid Fuel Burning or Gas Appliance form completed
5. Driveway Permit
6. Structural Drawings
a. Floor plans
b. Foundation plans
c. Cross Sections
d. Elevations
e. Window&Door Schedule
f. Natural Light,Ventilation and Emergency Egress
7. Plot plan:
Show proposed structure(s)with setback dimensions from all surveyed property lines
8. Electrical inspection agency selected
CHECKLIST—MULTI-DWELLING/COMMERCIAL Project Name: %Jos 1,13 .1 sncwAToz S
REQUIRED—2 SETS Yes No N/A
1. Building permit application completed �(
2. Energy Code COMcheck and inspector's report form completed x
3. Septic alteration
4. Solid Fuel Burning or Gas Appliance form completed
5. Driveway Permit
6. Structural Drawings
a. Floor plans
b. Foundation plan
c. Cross Sections ,X
d. Elevations
e. Design loads including floor, snow&wind load x
f. Seismic design X
g. Plans signed&sealed by registered architect or engineer
h. Window&Door schedule
7. Plot plan:
Show proposed structure(s)with setback dimensions from all surveyed property lines
8. Electrical inspection agency selected
Town of Queensbury Building&Codes Principal Structure Application Revised September 2015