applications Office Use Only
PRINCIPLE STRUCTURE PERMIT Permit#: QC— 051� - ?s�l5
APPLICATION Permit Fee:$
742 Bay Road Queensbury, NV 12804 *Rec. Fee: $
P 518-761-8256 Invoice#: �8t2a
Project Location: Cog 30 uO Ct.EU D6►� ��
Tax Map #: 2-°I S - Z- (o Subdivision Name: StS NN CLe-tio' +�' N)DbEN CsTAT,
TOWN BD RESOLUTION 86-2013 S850 recreation fee for new dwelling unk single family dup' :: s two-family,
multiplefamily apartments condominiums townhouses.and or manufactured A. modular homes but not mohiie
homes. This is in addition to the permit fee(s).
CONTACT INFORMATION:
• Applicant:
Name(s): F o b T H I LCS B E RS ( 3o E LEu c-t
Mailing Address, C/S/Z: m a un1 TR uNs lb vC' aufr S& i Ny 12r°11
Cell Ph.: t ( ct g ) 7R i - 1'i 33 L-a -Line: i (S-t1 ) 7?t6-3S2o
Email: Fo o Tt-(t i-t_5 3 u 1 L9ERS C—m A l c.. co rv\
• Primary Owner(s):
Name(s): SArnE AS A Ppt-tc flN-r
Mailing Address, C/S/Z:
Cell Ph.: ( ) Land Line:
Email: -
• Contractor(s): U AUG 01 2019 s
Name(s): S Amy AS A Phu CRNT
Mailing Address, CIS/Z: 8611.DiNC CO:!ES
Cell Ph.: _( ) Land Line: _( ) ^�
Email:
• Architect(s)/Enqineer(s):
Name(s): -NA r) `ky At-1 , PE LV l S i o t-) £NG-1 N 6'6 K iN C- )
Mailing Address, C/S/Z: 20 o G-c.€ SI Satre SG; GLc's FALLS N"{ )2- O I
Cell Ph.: ( ) Land Line: I (S't ' ) 19 2 - Z.tvy
Email: bf&1ANC YIStoNENG--. cm+giL
Contact Person for Building & Code Compliance: .)°6 LCN(-I
Cell Ph.: j_(S'tg ) 111- 1`j 33 hand Line: i(T-t 8 ) 19w- 3S2..o (t_c i)
Email: ("ooTH1(.LS tA Li) g.slpyef MAtt,-- Cor\
Tnrl Ruildine&Code Fnforrern nt PrinrinlP Stn,rnup RPviced Marrh 2018
PROJECT INFORMATION:
TYPE: Commercial X Residential
WORK CLASS:
`X Single-Family Two-Family Multi-Family(#of )
Townhouse Busness Office ____Retail Hotel/Motel
_Industrial/Warehouse Garage(#of cars ) Other(describe )
STRUCTURE SQUARE FOOTAGE: GARAGE SQUARE FOOTAGE:
1si floor: / 6 `I Y 1sT floor: y 7 C)
2nd floor: ----- 2nd floor:
3'd floor: /
Total square feet: '
Basement(habitable space):
Total square feet: I f Y
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ / 7 S , UV v
2. Proposed use of the building: I c� IL) T ►� L
3. If Commercial or Industrial, indicate the name of the business:
4. Source of Heat(circle one): Gas 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 Explain:
6. Are there any easements on the property? YES ;' NO
7. SITE INFORMATION:
a. What is the dimensions or acreage . e parcel? 0, (1c/2-(7
b. Is this a corner lot? YES i
C. Will the grade be changed as a re e construction? YES
_.,..._‘
d.What is the water source? PUBLI } PRIVATE LL
e. Is the parcel on SEWER or a PRIVATE SEPTIC system? lie-Iv AT II
Tn(l 8uiklina R Code Enfnrcemnnt Prinrinln Stn.-two RPvicnri Marrh?MR
DECLARATION:
I. Iacknowledge that no construction shall commence priorto issuance of a valid ouilding
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 1, or my agents, will obtain a
certificate of occupancy.
5. I understand that I/Ne 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: \(_: P tk LE is L/
SIGNATURE: 3)if�� DATE: Y ' I 1 ) 1
To()Buildine&Code Enforcement Prinrinln Str u-turo Rnvicn,$Marrh 7f11R
Office Use Only
sir). FUEL BURNING APPLIANCE & ems. 1
° Permit T • �t t�
CHIMNEY APPLICATION Permit Fee:
$
Invoice#:
74. Bry Road. Queensbu ; N`, 12804 P.
51 761-8256
Project Location: 68' 36 N C. N o 6•-) Tax Map ID: 2°I , l S - 2-
Room of Install: G- T -- ` Planned Install Date: l (i ( � I
**ONE APPLICATION PER APPLIANCE**
CONTACT INFQRMATION:
• Applicant:
Name(s): Fa o i H I LLS )auk I w E RS LLC ( J°6 Lett C d
Mailing Address, C/S/Z: q m Q N Ni li,N S i D e Qu e N S til y )28 C y
Cell Ph.: ( (S-ig ) `11 I- (q 3 3 �a #Line: ( 19m( c i S ) -3S2o
((ELL)
Email: Foo7KicLs P)L u1,.DeR3Nl G-(r f )t corm
• Primary Owner(s):
Name(s): cRrcrt" PIS AP/t.t c A NT
Mailing Address, C/S/Z:
Cell Ph.: _( ) Land Line: ( )
Email:
• Installer/Builder:
Name(s): S m As a pp L I(A N 1
Mailing Address, C/S/Z:
Cell Ph.: ( ) Land Line: ( )
Email:
Contact Person for Building & Code Compliance: 3'0€ LE-C I
Cell Ph.: I ( ) I - )'i 33 band Line: .j_( S) S ) hob - 3S-2.0
Email: - T. FocTM iu s elm LcE R-s G-m A)L, c tr•
Town ofOueensouryBudtl=n F r-,.j?Enforcn'ent
•
FUEL BURNING APPLIANCE INFORMATION: •
TYPE OF DEVICE:
Stove X Fireplace Insert Fireplace
wNi TE mcuN7aiN S Obe-L- Dvb3&FP3o?J TAH0C 1)6L-uXE
Fuel Fired Equipment(Garage Only,13"clea ra nce per IMC 304.3)
`Fireplace, factory built**
" Manufacturer's Name: Model#:
SOURCE OF HEAT:
Wood Coal Pellet (as J
CHIMNEY INFORMATION:
Masonry:
block brick stone
Flue:
tie Csle; /2-,size,in inches
Material*:
double-wall _ triple-wa It_insulated
("Manufacturer's r-1 a r-r,4as : Model#:
ADDITIONAL INFORMATION:
1 Two inspections are required. A rough-in nspection,prior to installation and a final nspection,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.
Declaration: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: ,v5e P H L.eu �-((
—
SIGNATURE : ,'\ ! `�� I I i 1 1
Fuel Burning Appliance himney Application
SEPTIC DISPOSAL PERMITAPPLICATION f°c. U 0111
71:Bay Road,Qu.arnbury. .1 is:0-1
P 518-76 '56 Perm; O C't If'2"-Z
Tax Map ID#: Sr 2-9C , IC- 2- 6,
Project Location: G SO I-I N C Le N D 0 r-) .3rsar:Ce? I
Primary Owner(s) , Fo 0 T H 1 L_L s F3tx i L b eg S LLc 1!�c r Le vi c-i)
Mailing Address
_.... � mLLANTAit�SID€ ir2 Qt.A6 NSBkQy N'J /2 U1
Phone & Email / DfRSN`1 �6 n lL.Cv+
_ti
I(ste)-'11t-(933 ! (c1019V3SZc FoaT(itLt-SBN1I
^Installer/Builder ! $iAmE ,AS Ar PLtC RAi `T
Mailing Address —. _-_-__ ___
Phone & Email --
Engineer To
--.-.-..-
- - _ CAN ER e.&••
{ Mailing Address i hp9 WWI LAN 1. Rc Qtage N S 13 tAl2 4 N y 12.$0 I
Phone& Email (S-1 $)19(G-2.T-( S TCCNTER36, @ YAHoo. Lbn'S
Contact Person for Buikfing&Code Compliance:3ae- Le &c/ Phc,r-t : CS1")191 - 1933
RESIDENCE NFORMATION: C Sf ff) 19 6- 2 d
Year Built #of bedrooms X gallons per bedroom = totaldaily flow Garbage Grinder Yes 1 o
1980 or older Installed? {circle one)
— Spa or Hot Tub Yes ;a 1981-1D91 -- - --
1992=Pfesent i 3
___ Installed? {circle one)
( 10 -- 36 1
PARCEL INFORMATION:
Topography_ -- °� Flat Rolling Steep Slope %Slope
Soil Nature bcSand Loam Clay _Other
Groundwater _ : At what depth? N ock
Bedrock/Imperviousmaterial ! At what depth? /.1 e\
Domestic Water Suppy 'Municipal _Well{if well.water supply from any septic system absorption is_it.)
Percolation Test ' Rate: I -"C per minute per nc h(test to be completed by licensed engneer/arcttect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size ( O 0 (.) gallons{min.size 1000 ga llons,add 250 ga lions for each garbage cylinder or spa/hot tub
System Absorption field with#2 stone Total length / co ft.:Each Trench co 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:lAlarm system&associated electrica(work must be inspected bya 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 gra nted 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.!
have read the regulations and agree to abide by these and all requirements oft he Town of Queensbury Sanitary Sewage
Disposal Ordinance. 1 p1i
PRINT NAME: `� 6S e T Li u 9 DATE. 8- ( 1 I 1 7
----'(
SIGNATURE: DATE:
41/11
Toil of Oueelsov .E: 0:;&Codes Enlbrcemenf
Town of Queensbury Thomas R.Van Ness
Highway Department Highway Superintendent
742 Bay Road,Queensbury, NY 12804 Home:518-745-0929
Phone:518-761-8211
Fax:518-745-4466 David Duell
Deputy Highway Superintendent
Home:518-745-0938
DRIVEWAY PERMIT
Date: Tit 1 ( 5
Applicant Name: Foo r H l L t S &S e- u L()
Telephone No.: 6S tf5 7 t - (1 33 /( 5 i )-196-35Zo
Address to be Inspected: G LLE, N D 6
Return Address: 9 mc TA ,Ns)DE A'
Qlne��SBtiRy N`t (ZF'C �
Applicant must show exact location and width of driveway(s)to be connected to the highway by placing stakes
at the specified location.
The Superintendent of Highways of the Town of Queensbury has reviewed this application. The following
action has been taken:
STEP 1: ( ) Preliminary approval
NEED ( ) Slight Swale
( ) Deep Swale
( ) Level with the road
( ) Level with the top of the paved wing
Size culvert pipe to be used (if necessary)
( ) 12" ( ) 15" ( ) 18" ( )24" ( ) 36"
Preliminary inspection completed by: Date:
Approval by Highway Supt.: or Deputy Supt.:
Upon completion please resubmit this approval permit for a final approval.
STEP 2: ( ) Final Approval ( ) Rejected
Date:
Thomas R. Van Ness, Highway Superintendent David Duell, Deputy Highway Superintendent
Town of Queensbury Building&Code Enforcement Principal Structure Application Revised February 2017