applications Office Use Only
(� ti , _ _ {� Permit#: R 'Q // Lf ZL�/
i PRINCI' • �, 11'1 ,� 5 / ,,
." \ al N AV •t. Permit Fee: $ $$,-�-
*Rec. Fee:$ KSQ. CIO
742 Bay Road. Queensbury, NV '�81, JUL 24 2019
P 518-761-8256 , ,1 ! , I. .' Invoice It: f $ 3 `-
TOWN OF QUEENSBURY
BUILDI G& COD
Project Location: 1'T17ZT•`ii�l�trr
Tax Map #: 308.1 - 1 ',rjO Subdivision Name:' arrin3er 4el1143
TOWN BD.RESOLUTION 86-2013:$850 recreation fee for new dwelling units: single family. duplexes/two-family,
multiplefamily, apartments. condominiums townhouses,and/or manufactured x modular homes, but not mobile
homes. This is in addition to the permit fee(s).
CONTACT INFORMATION:
• Applicant:
Name(s): 4-\ ).c cnLL.5k-\ \-I—PS
Mailing Address, C/S/Z: 19(, ' -)u r 8 e c k_ S1- lP-inO 4-o..cL ' 1 a'D(,.
Cell Ph.: _( ) Land Line: ( 5 IR ) '35 Co- (`}3S
Email: ►,1 bo c ou sKi-yo . c1ryi
• Primary Owner(s):
Name(s): M\55\pn emu\\ .erS
Mailing Address, C/S/Z: -mu, -burclery sE ScAneneL)"ae4 tO I 30(P
Cell Ph.: _( ) Land Line: _( 5aC ) 35( -
Email: yet I3.Q\noc0rouSk.a qy �
ouQ ' )
• Contractor(s): J
Name(s): V\t-1brtAl .,\ AtcreeS
Mailing Address, C/S/Z: TA tp l�urcA-es-1C St SJicnetc cL 10 130(o
Cell Ph.: _( ) Land Line: _(51 E ) 356 - 1 4 35
Email: tt@, \eo6.ocDu05V..ryc 4 Cif
• Architect s)/Engineer(s):
Name(s): r Skax \--\oer`e_ -Des\ccn S
Mailing Address, CIS/Z: 35 G\Grt wee 1_0n1- \ii \ion Nil
Cell Ph.: _( ) Land Line: ( 51K ) 30(A - 595I
Email: 3*\f,a.Z, \glog p_ n o- . re. Corn
Contact Person for Building & Code Compliance: Vcp
l Lc(0. t
Cell Ph.: _(,5 i R ) 368 - ��07 Land Line: _( )
Email: � fi.) hodoc-o�Skxr��cb• Corn
PROJECT INFORMATION:
TYPE: Commercial Residential
WORK CLASS:
/Single-Family Two-Family Multi-Family(#of )
Townhouse Business Office Retail Hotel/Motel
Industrial/Warehouse Garage(#of cars ) Other(describe )
-
STRUCTURE SQUARE FOOTAGE: GARAGE SQUARE FOOTAGE:
15T floor: g 3 +l, 1ST floor: 1-f-a +I
2nd floor: ci d 1 11— 2nd floor:
rd
3 floor: -�Total square feet: E Oa" ��
Basement(habitable space):
Total square feet: I$Co
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $
2. Proposed use of the building: 3'‘flJt? 'Fapn;
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)
S. Are there any structures not shown on the plot plan? YES NO Explain:
6. Are there any easements on the property? YES el
7. SITE INFORMATION: + ,
a. What is the dimensions or . eage of the parcel? • 91
b. Is this a corner lot? up NO
c. Will the grade be changed as a res - he construction? YES NO
d. What is the water source? PUB PRIVATE WELL
e. Is the parcel on SEWER or . PRIVATE SEPTIC stem?
DECLARATION:
I. l acknowledge 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
a II newly constructed facilities priorto issuance of a certificate of occupancy.
I have read and agree to the above:
PRINT NAME: ' n d \Ao c\bcc>uNS1L,
SIGNATURE: '� DATE: 1J9 1q
Office Use Only
•,.!`W '? FUEL BURN;NG APPLIANCE & Permit#: VC-01.94. - 2C) l�j
'Yrk CHIMNEY APPLICATION i
Permit Fee: $
Invoice#:
,)f Qtieensbn
742 Bay Road, Queensbury, NY 2804 P:
518-761-8256 www.quU=.n uu v net
Project Location: .59 .,cJnmrNrca \-Vx11 Tax Map ID: 3Og_ -1 - 1 - c5 o
Room of Install: 'V-ctz-nt coer-1 Planned Install Date:
**ONE APPLICATION PER APPLIANCE**
CONTACT INFORMATION:
• Applicant:
Name(s): HoclornL.>"Nk...k Ockne S
Mailing Address, CIS/Z: iq6 Luc desk 3* c '-)ei e o. c WI I R3Olo
Cell Ph.: _( ) Land Line: _(51 ) 356. - 1435
Email: a,,Q i _ VlpA er ouk:A QcOt, . coal
• Primary Owner(s): J
Name(s): `(YV;Ssion i�uk\ -ev--s
Mailing Address, C/S/Z: -79(Q 13L,,.r-ckt- 3 c a)c)nr-nc6-0.8'j l l y 1 P304o
Cell Ph.: _( ) Land Line: _( 5l k ) 35( - I4 35
Email: cp .LIQ Q Ir),0AncowsLgrc>►,..p . Conn
• Installer/Builder: JJ
Name(s): 08dcou)51L\ - ome5
Mailing Address, C/S/Z: 1cl le -P)ucderk._ 5r�ncncd-ad , N Y /R31
Cell Ph.: _( ) Land Line: _( c51& ) 35 c - J` ,55
Email: 66 \nu c:Iexpupsk+Jro , r orn
Contact Person for Building & Code Compliance: \--)43 exiy--at
Cell Ph.: _( 5 ►g ) 3(,5 - $gpl Land Line: ( )
Email: PP Q hnclnrou-Sk..oJcbuio. chr_r1
•
FUEL BURNING APPLIANCE INFORMATION:
TYPE OF DEVICE:
Stove Fireplace Insert Fireplace
_Fuel Fired Equipment(Garage Only,B"clearance per IMC 304.3)
_Fireplace, factory built**
** Manufacturer's Name: Pr't br Model #: 1' T aD35
SOURCE OF HEAT:
Wood Coal Pellet Gas
CHIMNEY(NFORMATION: �GD�;rer.--V- v .
Masonry:
block brick stone
Flue:
tie steel 4 size,in inches
Material*:
double-wall triple-wa li_insulated
(*Manufacturer's ri a m = Model #:
ADDITIONAL INFORMATION:
1 Two inspections are required. A rough-in hspection,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 nspections.
Declaration:Construction/installation must conform to NYS Fire Prevention&Building Code and/or manufacturer
requirements.The applicant or owner agrees to comply with aII 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: p�YOh� ._....
SIGNATURE : SATE: oZ I 11
Fuel Burning Appliance&Chimney Application
V
SEPTIC DISPOSAL PERMIT APPLICATI ON Office Use Onl
742 Ba Road,Queensbur
y,ry,\i1' 12SO4
P.518-761-8256 ;:,,,•.. Permt# oqc-11- " 11
Tax Map ID#: 300 . 1 - I -5D Permit Fee: Invoice#:
Project Location: 6 11 Septic Variance? Yes - N
Primary Owner(s) ,v1 ;r1)(-) .I c3er-
Mailing Address --I ct ec� Sk Sr (->-e.rlec.-k-act.4 , Ivy I
Phone & Email $I$ • 3510 • 1435 ect.La de_1n odor oL05V---4p�rpuP• Cpm
Installer/Builder d -�..Ns 14 orne 3 J
Mailing Address --IQU? tu -ele 3c_)r1Gnec..4--A , !�y /23cxo
Phone & Email J
5I$ • 354,• IL+35 � hodaco.,��lc►_c rnup• Ct Y \
Engineer \10-n DU.Sen 5-}-eves Land Sllr'vP C'S
Mailing Address IIPa 1-ACTQ 1Ctrl Like enc-1&L '�� Ny /age4
Phone & Email Jr I$ . 19
Contact Person for Building&Code c c mpliance: ��Q Crr kF'hori :518 . 3(o5 • 8 8O7
RESIDENCE NFORMATION:
Year Built # of bedrooms X gallons per bedroom = totaldaily flow Garbage Grinder Yes No
1980 or older Installed? {circle one)
1981-691 Spa or Hot Tub Yes No
—
Installed? {circle one)
. EJ92:Present
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,wate r supply from any septic system absorption is ft.)
Percolation Test Rate: per minute per inch{test to be completed by licensed engneer/arcttect)
PROPOSED SYSTEM FOR NEW CONSTRUCTI ON:
Tank size i gallons{min.size 1,000 gallons,add 250 ga lions for each garbage cylinder or spa/hot tub
System Absorption field with#2 stone ITotal length ft.;EachTrench ft.
Seepage Pitwith#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 electrica[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.
Declaration:Any permit or approval granted which is based upon or is granted in reliance upon any material
representation orfailureto 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 of the Town ofQueensbury Sanitary Sewage
Disposal Ordinance.
1
PRINT NAME: ?Q,�,t.,\ \AD c ocDL, \<j DATE: -]I�o���q
SIGNATURE: '�L- DATE: