applications :Office Use Only
PRINCIPLE STRUCTURE PERMITtiii
Permit#: g-C.-— 051-2.- 2pq.c)
APPLICATI ON
Permit Fee:$ I
Town of Queensbury,
*Rec. Fee:$
742 Bay Road, bu Queensly, NV 12804 �Ijr-
- 1 Invoice#: t
P 518-761-8256 www .queensbu y net
1
Project Location: 19 Westberry Way
• Tax Map #: 308:7-1-26 Subdivision Name: Sherman Ave Subdivision
TOWN BD.RESOLUTION86-2013:$850 recreation fee for pew dwelling units: single family,duplexes/two-family,.
multiplefamily, apartments,condominiums, townhouses-,and/or manufactured &Modular homes,but not mobile
homes_.This is in addition to the permit fee(s).
CONTACT INFORMATION:.
• Applicant:
Name(s): David Howard
Mailing Address, C/S/Z: 500.Luzerne Road, Queensbury NY 12804
Cell Ph.:. (518)361-0741 Land Line: (518)792-0222
Email: ,
1
• Primary Owner(s):
Name(s): David Howard
Mailing Address, C/S/Z: 500 Luzerne Road,Queensbury NY 12804
Cell Ph,,:(518)361-0741 Land Line: (518)792-0222
Email:
• ContractOr(s):
Name(s): David Howard
Mailing Address, C/S/Z: 500 Luzerne Road,Queensbury NY 12804
Cell Ph.: (51.8)361-0741 Land Line: (518)792-0222
Email:
• Architect(s)/Engineer(s):
Name(s): Rucinski Hall Architecture= Ethan Hall
Mailing Address, .C/S/Z: 134 Dix Ave, Glens Falls NY 12801
Cell Ph.: ( ) Land.Line: (518)741-0268
Email: ephall@nycap.rr.com•
Contact.Person.for Building..& Code:Compliance: Ethan Hall
Cell#.: (518)260-2888 Land Line: (51.8)741-0268.
Email:ephall@nycap,rr.com
Principle Structure Application, . Revised January 2019
n
PROJECT INFORMATION:
TYPE: ❑ Commercial at Residential
WORK CLASS:
• Single-family 0 Two-family ❑ Multi-family (#of units:
O Townhouse- 0 Business Office 0 Retail 0 Hotel/Motel
O Indutrial/Warehouse 0 Garage:(#of cars 0 Other(describe_)
STRUCTURE SQUARE FOOTAGE: GARAGE SQUARE FOOTAGE:
1ST floor:__1,152 1ST floor: 533
2"d floor: 910 2nd floor:,
-3rd floor:
Total square feet: 533
Basement(habitable space):
Total square feet: 2,062
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$_175,000
2. .Proposed,use of the building:_Single Family residence
3. If Commercial or Industrial, indicate the name of the business:
4. Source of Heat: IZGas DOH ❑Propane OSolar DOther:
(Fireplaces need a separate Fuel Burning Appliances&Chimney Application,one per appliance)
5`. Areithere any structures not shown on the plot plan? OYES ®NO Explain:
6.. Are there any easements on the property? DYES ENO
7. SITE INFORMATION:
a.What is the dimensions or acreage of the parcel? _1.29 acres
b. Is this a corner lot? I1YES ONO
c.Will the grade be changed as a result of the construction? ®YES ONO
d.What is the watersource? (PUBLIC ❑PRIVATE [DWELL
e. Is the'parcel on SEWER or a PRIVATE SEPTIC system? Private
Principle Structure Application Revised January 2019`
DECLARATION:
I. I acknowledge that no construction shall commence prior to issuance of a valid building
permit 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 approva-I.
3. I certify that the application, plans and. supporting materials are a true 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 lMte are required to provide an as-built 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: Ethan P. Hall -Architect\Agent for the Applicant
SIGNATURE: je#01
.7q(ast
DATE: 23 Aug 2019_
Principle Structure Application Revised January 2019
Office Use Only
,t �� - `. FUEL BURNING APPLIANCE & Permit#: '05-1-2.• 2Q\�
\N; , ?,;i CHIMNEY APPLICATION Permit Fee:$
Invoice#:
Tone of Queensbury
742 Bay Road, Queen sbury,NY MI
P: 518-761-8256 www .queensbury net
Project Location: _9 Westberry Way Tax Map ID: _308.7-1-26
Room of Install: _Living Room Planned Install Date: Sept 2019
**ONE APPLICATION PER APPLIANCE**
CONTACT INFORMATION:
• Applicant:
Name(s): _David Howard
Mailing Address, C/S/Z: 500 Luzerne Road,Queensbury NY 12804
Cell Ph.: (518)_361-0741 Land Line: (518)792-0222,
Email:
• Primary Owner(s):
Name(s): David Howard
Mailing Address, C/S/Z: 500 Luzerne Road,Queensbury NY 12804
Cell Ph.: (518)_361-0741 Land Line: (518)792-0222
Email:
• Installer/Builder:
Name(s): David Howard
Mailing Address, C/S/Z: 500 Luzerne Road,Queensbury NY 12804
Cell Ph.: (518)361-0741 Land Line: (518)792-0222
Email:
Contact Person for Building & Code Compliance: Ethan Hall — Rucinski Hall Architecture_
Cell Ph.: (518)260-2888 Land Line: (518)741-0268
Email:_ephall@nycapIrr.com
Principle Structure Application Revised January 2019
FUEL BURNING APPLIANCE INFORMATION:
TYPE OF DEVICE:
❑Stove ❑Fireplace Insert Fireplace
El Fuel Fired Equipment(Garage Only, 18"clearance per IMC 304.3)
®Fireplace, factory built **
** Manufacturer's Name: Quadra-fire Model#: QV-32
SOURCE OF HEAT:
❑Wood ❑Coal ❑Pellet IZ Gas
CHIMNEY INFORMATION:
❑ Masonry(requires plans to be submitted):
❑ block ❑brick ❑stone
❑ Flue:
❑ tile ❑ steel _size, in inches
Material*:
El double-wall ❑ triple-wall El insulated
(*Manufacturer's name:_Quadra-fire Model#: )
ADDITIONAL INFORMATION:
1. Two (2) 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.
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 of these 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: _Etha all — hit- _t " -.-nt for the Applicant
SIGNATURE: - ,� DATE: 23 Aug 2019
Principle Structure Application Revised January 2019
" SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
Permit#: 2Q1�
Town ofQucens:ury Permit Fee:$ : Invoice#:
742 Bay Road,Queensbury,NY 12804 Septic Variance? Yes No
P:518-761-8256 www.queensbury.net
• Primary Owner(s): Project Location: 9 Westberry Way
Name(s):_David Howard Tax Map ID#:_308.7-1-26
Mailing Address, C/S/Z: 500 Luzerne Road,Queenbury NY 12804
Cell Ph.: (518)361-0741 Land Line: (518)792-0222
Email:
• Installer/Builder:
Name(s): David Howard
Mailing Address, C/S/Z: 500 Luzerne Road,Queensbury NY 12804
Cell Ph.: (518)361-0741 Land Line: (518)792-0222
Email:
• Enqineer(s):
Name(s): Ethan Hall—Rucinski Hall Architecure
Mailing Address, C/S/Z: 134 Dix Ave, Glens Falls NY 12801
Cell Ph.: (518)260-2888 Land Line: (518)741-0268
Email:_ephall@nycap.rr.com
Contact Person for Building&Code Compliance:_Ethan P.Hall Cell Ph.:(518)260-2888
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms X gallons per =total daily flow
per day bedroom
1980 or older 150 _ _ Garbage grinder installed? ❑yes no
1981-1991 130 _ _ Spa or hot tub installed? 0 yes ® no
1992-Present 110 _3_ _110_ _330_
PARCEL INFORMATION:
Topography 0 Flat Rolling ❑Steep Slope _5_%Slope(after grading)
Soil Nature ®Sand ❑Loam ❑Clay ❑Other Click or tap here to enter text.
Groundwater At what depth?+72"
Bedrock/Impervious material At what depth? +72"
Domestic Water Supply ®Municipal F'i Well(if well,water supply from any septic system absorption is_ft.)
Percolation Test Rate:0'-30"_per minute per inch(soils to be amended per plan)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size 1,000 gallons(min.size 1,000 gallons,add 250 gallons for each garbage cylinder or spa/hot tub
System Absorption field with#2 stone Total length_200_ft.; Each Trench_50_ft.
Seepage Pit with#3 stone How many: :Size:
Alternative System Bed or other type:
Holding Tank System Total required capacity? ;tank size :#of tanks
NOTES:1.Alarm system&associated electrical 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 or failure to
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
by these and all requirements of the Town of Queensbury Sanitary Sewage Disposal Ordinance.
•
PRINT NAME: Ethan P.Hall—Architect\Agent for the Applicant av
SIGNATURE: iiga, DATE:_23 Aug 2019
Principle Structure Application • Revised January 2019