applications Office Use Only
rw
Permit#: C _ � 2 _� 11
;y';� ; ) PRINCIPLE STRUCTURE PERMIT
�. APPLICATION Permit Fee: $ZZ �1 1¢ .Z0
742 Bay Road; Queensbury, NV 12804 *Rec. Fee: $ �JrDO
P 518-761-8256 „.,,.•; •:,i:e.,: -, r--., Invoice #: 1-1-1
Project Location: 74 r ]iC )mono \I Y. \ri'(e-
Tax Map #: 3 0', 7 - ( - 7 a Subdivision Name: l rr ; r r 4 ' +-
TOWN BD.RESOLUTION 86-2013:$850 recreation fee for new dwelling its: n e family,d axes/ o.kamily,
multiplefamily, apartments. condominiums townhouses,and'or manufact rLI do
! mdulac,llo but t;mobile
homes. This is in addition to the permit fee(s). iJ •J+UJ" CL 1 ZU13
CONTACT INFORMATION: TOWN OF OUEENSBURY
BUILDING&CODES
• Applicant:
Name(s): Hocicxo u).S I,AameS
Mailing Address, C/S/Z: 7q(p i)Du AecY, Sc c-,enrt_A-o , /\[y (a 3O(
Cell Ph.: ( ) Land Line: _( 51 k ) 356, - l 35
Email: Q cgs Allecbro i_Ski a cc urp. Corn
• Primary Owner(s): J
Name(s): YY1‘‘ 55'‘oc �jLk; k e,(--
Mailing Address, C/S/Z: 19 L, �t_L-clec \ SdlPricr4 �3, 1\y 1a30X
Cell Ph.: ( ) Land Line: (S/E ) 351. - l(-1-:'1)5
Email: (")0..i..1 @, horlorok.osk o -o . Corn
• Contractor(s):
Name(s): \--}(ThCkeir-0LS k-:l \-k ,c.5
Mailing Address, C/S/Z: -1 ct CQ '-)ur cAerv, Sc h ncGi- , t H la 3p(p
Cell Ph.: _( ) Land Line: ( 51Q 3 54 -1-35
Email: p n LIA L \c\u Arx0f51c rou.. . Gorr)
• Architect(s)/Engineer(s): J
Name(s): /Jc5( a c- }Eomc DeS i ov5
Mailing Address, C/S/Z: 35 Chcroi -Ti-er_ L4nr W;; 1 4-bn i NI
Cell Ph.: ( ) Land Line: (5 I k ) 3 n(o -5957
Email: J KG,-z—lq 6 c, r . r r• C(yn
Contact Person for Building & Code Compliance: Peo &cca51,
Cell Ph.: ( 5I ) 3(.5 - $go 7 Land Lin ( )
Email: c.rr (�. ,nprtnrrowSk.; Jcott.4e. ('QM
PROJECT INFORMATION:
TYPE: Commercial ✓ Residential
WORK CLASS:
✓Single-Family Two-Family _Multi-Family(#of )
Townhouse Business Office Retail Hotel/Motel
Industrial/Warehouse Garage(#ofcars ) Other(describe )
STRUCTURE SQUARE FOOTAGE: GARAGE SQUARE FOOTAGE:
1
n floor: 1a7a fi/_ 1sTfloor: 1-I`±1 +1
2nd floor: 95 a +1_ 2nd floor:
I—
3rd floor: Total square feet: i"t'L'F'� +
Basement(habitable space):
Total square feet: aaa4
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ aor), coo
2. Proposed use of the building: 5,r cj [IO P1 iei
3. If Commercial or Industrial, indicate the name of the business:
4. Source of Heat (circle one): Oil Propane Solar Other:
(Fireplaces need a separate Fuel Burning Appliances&Chimney Application,one per appliance)
5. Are there any structures not shown on the plot plan? YES NO xplain:
6. Are there any easements on the property? YES er,
7. SITE INFORMATION: II
a. What is the dimensions or acreage • he parcel? 5
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? PRIVATE WELL
e. Is the parcel on SEWER or a6RIVATE SEPTIC tem?
DECLARATION:
I. lacknowledge that no construction shall commence priorto issuance of a valid building
perm and work 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 approva I.
3. I certify that the application, plans and supporting materials are a t rue 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. I acknowledge that prior to occupying the facilities proposed I, or my agents, will obtain a
certificate of occupancy.
5. I 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: "PQ\ t--\pc\m-b .)S i
SIGNATURE: DATE: / oJi
Office Use Only
FUEL BURN'NG APPLIANCE & Permit#: 0462- ZO\cl
• / CHIMNEY APPLICATION Permit Fee: $
Invoice#:
Quee nsbu
742 Bay Road, Queensbury, NY 12804 P:
518-761-8256 wwr. net
Project Location: 19- 'RICl-lmb b•Tax Map ID: 308 . 1 - - 7a
Room of Install: L-'((c cOm Planned Install Date:
**ONEAPI LICATION PER APPLIANCE**
CONTACT INFORMATION:
• Applicant:
Name(s): \-\cmcs
Mailing Address, C/S/Z: 'c_.,kr)-es-sec-4-&cam NV /a 30(P
Cell Ph.: _( ) Land Line: _( 5 I ) 354 - 1�35
Email: ,ea li I (co \nodr rnLiDsk-Agrr)1/4 ,_,P. Corn
• Primary Owner(s): J
Name(s): H h SS.‘on 2-.).t�� 1 Act- s
Mailing Address, C/S/Z: -rq(o 13t,.-ckec‘", St, 36'wJ-0_16, Ny l . 30(e
Cell Ph.: ( ) Land Line: ( Sig ) 35(0 - (`-f35
Email: ,k)ctv X G \noc\p-n<.mSK.a (o . Corn
• Installer/Builder:
Name(s): -lockrows 1-\nmcs
Mailing Address, C/S/Z: -79(0 r8ecN, ,ncc1r i -, 1\1`/ /a30,
Cell Ph.: _( ) Land Line: _( ) 35(0 - 1435
Email: o,„ Q hnancc SK cs( . corn
Contact Person for Building & Code Compliance: ?P Cnc c
Cell Ph.: _(51S )_45 - $yb-1 Land Line: r_( )
Email: � C . hoc\o _okosk1(yo..►.,7. corn
FUEL BURNING APPLIANCE INFORMATION:
TYPE OF DEVICE:
Stove _Fireplace Insert " Fireplace
Fuel Fired Equipment(Garage Only,B"clearance per IMC304.3)
_Fireplace, factory built**
** Manufacturer's Name: 5(ipPri ar Model#: -DR 1 o35
SOURCE OF HEAT:
Wood Coal Pellet
CHIMNEY(NFORMATION:
�I e4 05 d;rec,-( e r*
_Masonry:
block brick stone
Flue:
tie steel size,in inches
Material*:
double-wall _ triple-wa Il_insulated
(*Manufacturer's Model#:
ADDITIONAL INFORMATION:
1 Two inspections are required. A rough-in inspection,prior to installation and a final inspection,after
installation.
2 Manufacturer's installation manual must be available at the time of inspection.
3 Masonry fireplaces & chimneys require plans to be submitted.
4 Twenty-four (24) hour notification 's required for inspections.
peclaration:Construction/installation must conform to NYS Fire Prevention&Building Code and/or manufacturer
requirements.The applicant or owner agrees to comply with all applicable laws,ordinances,regulations and all
conditions that are part ofthese requirements and also will allow the inspector to enter the premises to perform the
required inspections. ,
I have read and agree to the above:
PRINT NAME: ( —
SIGNATURE : _ — OAT E: 6 (q
Fuel Burning Appliance&Chimney Application
�.� SEPTIC DISPOSAL PERMIT APPLICATI ON Office Use Onl
Ya 742 Bay Road,Queensbury,NY 12804
P.518-76 I-8256 . Perms#: 2
�C -Qq 1jL -
Tax Map ID#: ,3O$. 1 - ( - 7 Permit Fee: •Invoice#:
Project Location: ,_3L Y\, )cI'cnun U t'k;„ 1)f.,v>✓ Septic Variance? Yes 1\10
Primary Owner(s) MSS on- U«-+ 18c 5
Mailing Address 1a4 -bur S&.- 3c_henerJr-adt� Ny Ia3c (
Phone & Email 518 , 5L, • I+ P @ hodocOwSk_ o p. CAm
Installer/Builcier U��cXOwS� �p,m�S J ``
Mailing Address k + / ,Vy
Phone & Email 518 3 56a. I 41.3 5 Qc 6). hock c-deos ► Af b •aern
Engineer V ct-n—Du-"%2X1 4 S-k'Gfe5 Land 9urVP.k.\7JJC; .
Mailing Address (Cq 1-A0.vd 10.nc ?c QUftos c u,.cu�
Phone & Email
1.
Contact Person for Building&Code s c mpIiancc�:/?ePC""--c ' Ph con es:51$. 3(05. 8$07
RESIDENCE NFORMATION:
Year Built # of bedrooms X gallons per bedroom = totaldaily flow Garbage Grinder Yes No
1980 or older Installed? {circle one)
1981-f991 Spa or Hot Tub Yes No
Installed? {circle one)
92=resent
PARCEL NFORMATION:
Topography —� — Flat Rolling Steep Slope % Slope
Soil Nature _Sand Loam Clay _Other
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 engneer/arcl-tect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size gallons{min.size 1000 gallons,add 250 ga lions for each garbage cylinder or spa/hot tub
System Absorption field with#2 stone 1Total length ft.;EachTrench ft.
Seepage Pit with#3 stone How many: Size:
Alternative System Bed or other type:
HoldingTank System Total required capacity? .tank size ;# of tanks
NOTES: 1.Alarm system&associated electricalwork must be inspected by a Town approved electrical inspection
agency;2.We wi II 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.
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.l
have read the regulations and agree to abide bythese and all requirements oftheTown ofQueensbury Sanitary Sewage
Disposal Ordinanc
PRINT NAME: OA 4 DAD c DATE:
k-�, Ct lgoliq
SIGNATURE: DATE: (O ail
I