applications PRINCIPAL STRUCTURE APP . A� •
If- ( ce Use Only
eived
q 14 2015 Date: ' o'� °/)-/-&1Map ID � . � '�-�/
SFT' j 0 2015 ''- mit No. �a t5-42.-5
Tax Map ID II' mit Fee 4 I rl 9 / 07 '
Zone TOWN OF QUEENSS(JRY • c Fee O
UILDING& CODES to Plan#
Historic Site Yes No
Subdivision Name Lot# bdivision# a4t64014
TOWN BD. RESOLUTION 86-2013: $850 RECREATION FEE FOR NEW DWELLING UNITS - SINGLE
FAMILY, DUPLEXES/TWO-FAMILY, MULTIPLE FAMILY, APARTMENTS, CONDOMINIMUMS,
TOWNHOUSES,AND/OR MANUFACTURED&MODULAR HOMES,BUT NOT MOBILE HOMES. THIS
IS IN ADDITION TO THE PERMIT FEE.
Applicant
I.R (/►4. Owner 5 ► ( [Ai
4(e.s
Address ativilityl?it Address /4 j)a1hz(dLth (12d
LLe eo , e, ez/M
Phone/E-mail 3,097 Phone/E-mail Dig -13Z- 1
Contact Person for Building&Codes Compliance: Phone
TYPE OF CONSTRUCTION
✓Check all that apply New Addition Alteration 1St floor sf 2'floor sf Total sf Height
Single Family7r
di m '.SIO)(Gig.)
lQ
Two-Family cr-;QA 2
Multi-Family
(#of units )
Townhouse
Business Office
Retail -Mercantile
Factory- Industrial
Attached Garage
(1,(t3, 4+) ✓
Other
Town of Queensbury Building&Codes Principal Structure Application Revised September 2014
r �
•
If commercial or industrial please indicate of business
Proposed use of building or addition l)yyy{ f ri(1
Source of Heat(circle one) c&ta.ja
asi Propane Solar� `� Other
Fireplace: Complete a separate application for Fuel Burning
Appliances & Chimneys
Are there structures not shown on plot plan?
Are there easements on the property? jJa
Site Information
a. Dimensions or acreage of lot
b. Is this a corner lot?
c. Will the grade be changed as a result of construction Yes No
d. Public water or Private well prtita :
e. Sewer or Private Septic System i S '
Value of all work to be performed (labor or materials) $ 91 0 g
DECLARATION:
1. I acknowledge no construction shall be commenced prior to issuance of a valid permit and will be completed
within a 12 month period.
2. If work is not complete by the 1 year expiration date the permit may be renewed, subject to fees and
department .
3. I certifyepthat theapprovalapplication,plans and supporting materials are a true and complete statement/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 also 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 agre: to the above:
PRINT NAME: `l 1 ! DATE: "t 2Db
ir
iit
SIGNATURE: 1E1r , d1
DATE: 16
For office use only
Operating Permit Issued: Yes No
Occupancy Type
Construction Classification
Assembly Occupancy Limit
Special Conditions
Town of Queensbury Building&Codes Principal Structure Application Revised September 2014
SEPTIC DISPOSAL APPLICAF;K C rE 0 V Effie Lase Only
1 Recei ell
DATE: 9 Zi , 117 SEP 21, 21115 Tax ap ID
� I P ' Mo.
TAX MAP ID: � _
; ` (
TOWN OF QUEENSB it F ee
ZONE: BUILDING& CODES
APPLICANT W 1 1 l 1 A 04 c Ie5 PHONE/E-MAIL 793 !
ADDRESS A W j1C j OC 11 I
INSTALLER/ / PHONE/E-MAIL
BUILDER �Jl�_�1/� • Vii(
OWNER j / J i'�i I
ADDRESS
CONTACT PERSON FOR BUILDING&CODE COMPLIANCE:
PHONE/E-MAIL
RESIDENCE INFORMATION 1
Year Built #of bedrooms X gallons per bedroom =total Daily flow
1980 or older I Garbage grinder installed _Yes XNo 1
1981-1991 Spa or Hot Tub installed _Yes XNo
1992-Present I
PARCEL INFORMATION
Topography X Flat rolling Steep slope %Slope
Soil Nature Sand )( Loam Clay K Other
,Groundwater At what depth: 7 , Fr
Bedrock/Impervious material At what depth:
Domestic Water Supply Municipal X 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 engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION 4
Tank size I Ivo gallons(min.size 1,000 gallons,add 250 gallons to size for each garbage cylinder or spa or hot tub
System Absorption field with#2 stone 1 Total length 1ZC) ft.;Each Trench 4
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)W
no longer allow systems to be covered until such time as an As-Built plan is received&approved. The installed system must ma
septic system layout on file–no exceptions.
Declaration: Any permit or approval granted which is based upon or is granted in reliance upon any material representation
to make a material fact or circumstance known by or on behalf of an applicant,shall be void.I have read the regulations a
abide by these and all requirements of the Town of Queensbury Sanitary Sewage Disposal Ordinance.
PRINT NAME: A ! i!,. DATE: i izi I l`j'
SIGNATURE: R��j�;,, r, 411111�-1 DATE:
Town of Queensbury :uilding&Codes Principal Structure Application Revised September 2014
1
Compan ,.,. g '
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tic '_, f) ,e-(Y
J
Z.!.S. Sep tic c' Drain Service Znc 4,-r
DBA CONDON'S SEPTIC SERVICE �A -t.. --
2 Lower Warren Street • Queensbury, NY 12804 t_ r ,; ;.
Phone: 518-798-8194 • Phone:518-798-8542 • Fax:518-798-3213 We take pride in e erything we do!
NAMES I ,,
4 t f - (� DATE CA 7/ IfJ y; 1"-- DATE C *Vix '_'
1 STRE�T/1' ACKS)UP
/
I OYES ONO
TOWN JOB END TIME GAL. TANK UNCOVERED
OYES ONO
PFNZ/OMS/a 'j WORK CELL START TIME•SIZE TANK DEPTH TANK SIZE
CONTACT PERSON END TIME•SIZE QUOTED PRICE 'DTIC
DIRECTIONS f,l. f 0 GREASE
07 4/ 1 t- 1 IP' ,.6 ._19-" 4 - ,
, li"," X if'(/ '- 6 ' 'Lt I 4. 6 'r-
SEPTIC EVALUATION TANK: OK YES 0 NO 0 OUTLET BAFFLE: OK YES O NO 0
TANK SIZE FIELD: OK YES 0 NO O INLET LINE: OK YES O NO O
LIQUID LEVEL: 4, TANK CONSTRUCTION MATERIAL:
NORMAL O HIGH O CONCRETE O PLASTIC O METAL O VENTS: OK
ESTAGE OF SYSTEM: EST VISIBLE AMOUNT OF LEACH LINES
TESTING OF INLET LINE: FLUSHED TOILET YES O NO O
f 8 /
SEPTIC SYSTEM NOTES: `� 0 j {- ,`0 d f , _ AI nil-0 C lf.� r ��L,}
e - ( roti h !,! ."11 - a t'` , .. rj
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/ ie A� ..yzy tah1/ � ������-env � - /�� rgrAve
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DESCRIPTION=`.i ` "'- :+ . •,i� "Yzt AMOUNT
PUMPING OF SEPTIC TANK: GALS.@
GREASE TRAP: GALS. @ / '',02,.
, C�}i C( 11 f 5Q
CLEANING LINES WITH SNAKE !
1 i5 dee 2 2 5-- 1
9
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WE WILL SEND YOU A REPUMP REMINDER IN YEARS. SUB TOTAL C 3 8
AUTHORIZED SIGNATURE �`
PROCESSING FEE
TERMS: A Late payment charge of 2%per mo.
shall be payable upon all unpaid balances over 30 days. Collection Costs,including reasonable TAX% "�� / . e(1-7--
Attorney Fees,will be charged to the Customer. There will be a$50.00 charge for all returned checks. TOTAL
Plii
Method of P.yment: O CASH O CREDIT CARD O CHECK '' ' ' ¢
Please charge to my: O MasterCard O Visa Card No. Exp.Date
fi i
Signature:
I
MP IBS-1 Rev.06/11 W-Office Y-Customer