applications Office Use Only
✓ Permit#: 2C - 0 37/ `ZC(
-) PRINCIPLE ST nn
. APPL i V E t Fee:$ f 77 60
c Fee:$ S° ' pl)
742 Bay Road,Queensbury, NV 2804 AUG 302019
II __ O
P: 518-761-8256 :,�°:: :,t:+..5 �. - o e#: 7 l�
TOWN OF QUEENSBU Y
BUI DING& CODES
Project Location: --ft 9ichmnn
Tax Map #: �ng . - - 1 -75 Subdivision Name: ' rrkr►9er I-Eeis\4
TOWN BD.RESOLUTION 86-2013:$850 recreation fee for new dwelling units: single family,duplexes/two-family,
multiplefamily, apartments,condominiums townhouses,and/or manufactured R. modular homes, but not mobile
homes. This is in addition to the permit fee(s).
CONTACT INFORMATION:
• Applicant:
Name(s): i-Iorrpcno.)5K 1-IomeS
Mailing Address, C/S/Z: '19(D 'P)LurdecK S-L ScAlenec od.1J, 1 a3oc ,
Cell Ph.: ( ) Land Line: ( 5i8 ) 3510 . 1435
Email: ca LQ @ heclOcou)Ska you.Q• Cam
• Primary Owner(s):
Name(s): 1 1.S3 on (hers
Mailing Address, C/S/Z: -q(D Pur rier Sc ac _ f\f`1 /a3iL,
Cell Ph.: _( ) Land Line: ( 51 g ) 3510 • P-I-3 5
Email: (:)110. .lnoclrnu.)ski �rox . e rr,
• Contractor(s):
Name(s): N octora►2.,I6 \t rne_S
Mailing Address, C/S/Z: 191Q buarcke4 ')clie ler.-1-ac , N y 1 a30(o
Cell Ph.: _( ) Land Line: _( ) 351P • 1435
Email: ,P ,Q @ \-\odorotsk._%you.P_ Corn
• Architect(s)/Engineer(s):
Name(s): Nome De.,s; ncs
Mailing Address, C/S/Z: 5 C' e. ►1.6, NY
Cell Ph.: _( ) Land Line: _(,5 ' ) 30G - 595/
Email: 3V-ial..Z..14fc8 @ nbca.P, cr. Corn
Contact Person for Building & Code Compliance: '--PeAD C,prcp-
Cell Ph.: (518 ) 3(,5- k8 07 Land Line: ( )
Email: Peso hcx brow rOu ). 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:
srfloor: 5' 5
1sT floor: I 5 q 4- 1
a �—
2„d floor: 2nd floor:
3 rd /
floor: • Total square feet: Sa5 t
Basement(habitable space):
Total square feet: 15 a t/
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ &0O, 000
2. Proposed use of the building: S;note cku-r1;1. cL ell i '
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 ClExplain:
6. Are there any easements on the property? YES
7. SITE INFORMATION:
a.What is the dimensions or acreage o the parcel? LEG, +/'
b. Is this a corner lot? YES
c. Will the grade be changed as a res - +e construction? YES
d. What is the water source? •UB - PRIVATE WELL
e. Is the parcel on SEWER or PRIVATE SEPTIsystem?
DECLARATION:
I. I 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 lyear 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 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 Ike are required to provide an as-bui ft survey by a licensed land surveyor of
all newly constructed facilities priorto issuance of a certificate of occupancy.
I have read and agree to the above:
PRINT NAME: "P ocbcD u�SIG
SIGNATURE: �� ____ DATE: S �� l°I
Office Use Only
FUEL BURNING APPLIANCE & Permit#: P�. —ti'�.�'► ( ••
CHIMNEY APPLICATION Permit Fee:$
_ Invoice#:
of Qcceensbu
742 Bay Road, Queensbury, NY 12804 P:
518-761-8256 www quern. LL V net
Project Location: 78 1- iChmond Ji)l br.Tax Map ID: 308. 7 -I - 73
Room of Install: Fatrn t y ?loom Planned Install Date:
**ONE APPLICATI ON PER APPLIANCE**
CONTACT INFORMATION:
• Applicant:
Name(s): --1o801-0,1,.,s1<; c)mtn
Mailing Address, C/S/Z: '7q(e i3u.rcleck S{ Jier)eeor , nJ`I 1 a(30(0
Cell Ph.: _( ) Land Line: ( 518 ) 35c, - 1`I-35
Email: P cuij \no8.broupsk'%gcc�uq• cbrr
• Primary Owner(s): JJ
Name(s): Mission emu:,icier-5
Mailing Address, C/S/Z: 1q6 'Eurder 51 �c�P�nPc ad, l�`/ /a30(0
Cell Ph.: _( ) Land Line: _(5tg )/354 - / -35
Email: eft,LQ Q Vr ocInco a skli aft Ou . ('.gym
• Installer/Builder:
Name(s): pclnrr)u1 sk - omr_S
Mailing Address, C/S/Z: -7q 1, -Eu,c-APr_1( 3{• 361c.necka..L N y 12304,
Cell Ph.: ( ) Land Line: _(,S/k ) 35(a - /q35
Email: cxt„Q qc p e.rm
Contact Person for Building & Code Compliance: Yep Ctxio.di
Cell Ph.: _(51 R ) 3(05 • $80-1 Land Lin&: ( )
Email: p9•3CQ lnoddre lc; ro�, , LAM
• FUEL BURNING APPLIANCE INFORMATION:
TYPE OF DEVICE:
Stove Fireplace Insert 7-Fireplace
Fuel Fired Equipment(Garage Only,'B"clearance per IMC304.3)
Fireplace, factory built**
** Manufacturer's Name: �te..ei o r Model#: r' \ ac)n5
SOURCE OF HEAT:
Wood Coal Pellet Gas
CHIMNEYJNFORMATION: NIA �iCet,} Vex)1-
_Masonry:
block brick stone
Flue:
tie steel size,in inches
Material*:
double-wall triple-wa II_insulated
(*Manufacturer's r ti a m = 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 is required for nspections.
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: RILA.1 k0 AO(-0 —
SIGNATURE : t IRATE: )-- I�
Fuel Burning Applia ce&Chimney Application
' SEPTIC DISPOSAL PERMIT APPLICATI ON Office Use Onl
-`' ' 742 Bay Road,Queensbury,NY 12804
P.518-761-3256 • ;:.,,..�.;:::;,r r Permt#: Q,C o51( • zo tot
Tax Map ID#: 3 o —1' - 7S Permit Fee:S •Invoice#:
Project Location: ChM %\ Septic Variance? Yes - IV o
Primary Owner(s) MiSsion 3v.1 l decs
Mailing Address -1% '6u-rrier iencthaA NIN lablo
Phone & Email 5,g. 35G • 1435 ectAAAD. kodarouasKi ro c.4. e r
Installer/Builder Hodof oL51 .k-t0(ne5
Mailing Address -RI. TAArdcric.. St Sehene-cka , N'L 12 o(,
Phone & Email i
^^..
5/& •35te • i435 ecui tZ Inndnra.�nc,ru.p.COm
Engineer \L Dt Sert q- AeVG.S Lan x-VP��or5
Mailing Address 1(�c1 3-,roavA 'Q d C"��eanSbuu , t•f Y /a80�f-•
Phone& Email SIB • 7q a • 8y74 0 Contact Person for Building&Code C,omp1iance:Pee Crwet.ct F' co
n :c518 • 3(.5 . 8g07
RESIDENCE NFORMATION: _
Year Built #of bedrooms X gallons per bedroom = totaldaily flow Garbage Grinder Yes No
1380 or older Installed? {circle one)
1981-1991 Spa or Hot Tub Yes No
Installed? {circle one)
' 9'2-Present -
PARCEL NFORMATION:
Topography Flat Rolling Steep Slope %Slope
Soil Nature _Sand _Loam Clay _Other
Groundwater At what depth?
Bedrock/Imperviousmaterial 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/arcliect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size gallons{min.size 1,000 gallons,add 250 gallons for each garbage cylinder orspa/hot tub
System Absorption field with#2 stone 'Total length ft.;EachTrench ft.
Seepage Pitwith#3 stone I How many: -Size:
Alternative System !Bed or other type:
HoldingTank System Total required capacity? .tank size ;# of tanks
NOTES:1.Alarm system&associated electrica lwork 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 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.I
have read the regulations and agree to abide bythese and all requirements oftheTown ofQueensbury Sanitary Sewage
Disposal Ordinance. 1 I
k PRINT NAME: O dorm., DATE: 'R/2?..j j9
SIGNATURE: DATE:424a-
_