applications I ,
f PRINCIPLE STRUCTURE Office Use Only
ry ' PERMIT APPLICATION 3�� I
Permit#: /
Town ofQueensbury -A05e Or p� Permit Fee: $ Al;- S� ' 1 v�,v
r i
742 Bay Road,Queensbury, NY 12804 *Rec. Fee: $ &5�----
P: 518-761-8256 www.queensburynet 146.0 SF //
Cp,�irYAL, uy` Invoice#: i 6-a~5
Project Location: /5 //eA//` 0/"Ze d`2/1d �k°tc� A,z' ilce L-t...1 `1 St iOAT.
l' Tax Map #: 15 ' ( VC) -36' I Subdivision Name: a✓,4/J 1-1113/21OI5kA
TOWN BD.RESOLUTION 86-2013:$850 recreation fee for new dwelling units: single family, duplexes/two-family,
multiple family, apartments,condominiums, townhouses,and/or manufactured & modular homes,but not mobile
homes. This is in addition to the permit fee(s).
CONTACT INFORMATION:
• Applicant: /V) '1 ,
/// ._ !G , //Ucoo/v Name(s): N5
)
Mailing Address, C/S/Z: 2'2 e,,4.Go$2/ h/A...! ,Q.t/JA-Vei2a7- AV /ZY3l
Cell Phone: ( Si8 ) 935-- 5707/ Land Line: ( ) Al
E m a i I: /`itr:05/n0 SI-&jr74,,Z e.o"
• Primary Owner(s): ,�/ �/
Name(s): �AiIiE 4S /43eci/t.;
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: ( )
Email:
• Check if all work will be performed by homeowner only
l
lid,e;rhafrael;
• Contractors : Workers' Comp documentation must be submitted with this ap:lication
Contr c o% re s): ille{ onr : j im e5ilbepl. t6ir vv1 ((e,WY
aztcr raele: (u g edrn4-a ( • , 01i4-4 t- M i ke 7)ic_i<;n)sor
p[1aiii-n--g ci— ,' C/S/Z: ' vyjii ✓i " Amer"" Zokk s , N 7
CeellEh ne: ( ) 1 4 UJ Clxand Line: ( )
En=a--it. " SCtr-c.-h)cam. 5io✓1' i 1\1 Y 0.1`S4- r
o
**List all additional contractors on the back)of this fbrm 0... tcfi
P4
• Architect(s)/Enqineer(s):,
Business Name: 4, c I/ 7 /
Contact Name(s): JAy / /Vi E�/,' cle i
Mailing Address, C/S/l /Q 2icze , l4 -'-7 ' - "'- Ai,�/l2a?
Cell Phone: 5/v )32/-1o/off (J17) Land Line: ( ) A
Email: l ,
e iC. Arui/�OC jdm/L. co/4
Contact✓ Person for Building & Code Compliance: Jeff aAilz
Cell Phone: (5/6 ) 32/—c 'I 3 Land Line: ( ) Nib.
Email: �6GF. arcs-I-t1OeL �,4/4 cdr"
Principle Structure Packet Revised February 2019
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): arnC1%\be✓t'
Contractor Trade:
Mailing Address, C/S/Z: CrO,vwA`c., tyy
Cell Phone: ( ) Land Line: ( \ )
Email:
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): c) t,ow\a arvyexs
Contractor Trade: "TY ,n‘
Mailing Address, C/S/Z: Audsv,CONks M'-
Cell Phone: ( ) Land Line: (
Email:
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): COr,k V\vtik Z_
Contractor Trade: Yer, y6
Mailing Address, C/S/Z: c.„.rG\-„ � r, � �y
Cell Phone: ( ) Land Line: (
Email:
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: (
Email:
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: (
Email:
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: (
Email:
Principle Structure Packet Revised February 2019
PROJECT INFORMATION:
TYPE: Commercial A Residential
WORK CLASS:
X_Single-Family Two-Family Multi-Family(#of units )
Townhouse Business Office Retail Hotel/Motel
Industrial/Warehouse Garage(#ofcars ) Other(describe )
STRUCTURE SQUARE FOOTAGE: GARAGE SQUARE FOOTAGE: c7,tt ?( 4-t,Lt
nn
1sT floor: 41 /r 1� Ivy V - ' 1sT floor: l 'Z� 1 G�'
0U S , ,j_J�
n Ii /(o• w`
{�1Kk4� � 0 2 d floor: �' 5�;�, �'c'/.
-3�-Ftoor: X. tAe S �5�+�
Total square feet:
o ram+ I h4a h;+- ,i„ ----+ '� CI
„ s i-
s `� r
arc. cf A----T �� rw•
_6L4tAre_
1/4., a .7 , )
T - L 7Dg s Se . --
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $19 01
2. Proposed use of the building: \O - --
3. If Commercial or Industrial, indicate the name of the business:
4. Source of Hea 0 Oil Propane Solar Other:
(Fireplaces nee. . 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? 6_E.5) NO
7. SITE INFORMATION: Z ii
a. What is the dimensions or acreage ofrt- e parcel? -1 1
b. Is this a corner lot? YES NO --�
c. Will the grade be changed as a result,e -t-Iconstruction? YES < CVO)
d. What is the water source? PUBLIC PRIVATE WELL
e. Is the parcel on SEWER or a PRIVA EPTIC system? 9:3?-\' - Lt✓
Princinle Structure Packet Revicprl February 7n19
c a
DECLARATION:
I. I acknowledge that no construction shall commence priorto 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 1year 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 INve 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: ry iIK - b f'-kfkJso&f
SIGNATURE: nk DATE: 5l A iq
Principle Structure Packet Revised February 2019
Office Use Only*
Permit#: ''0603-201
Town°I.Q-ue"sburY SEPTIC DISPOSAL PERMIT APPLICATION
Permit Fee: $ ; Invoice#:
Septic Variance? Yes No
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net
Tax Map ID#: RLi V?"
Ai L3 '
Project Location: 1 K&'in'Ir71 ei,�✓(�: � ;,,-
• Applicant:
Name(s): k.<13,IniScorN
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _(
Email:
• Primary Owner(s):
Name(s): M kc.1-1►rsc
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _(
Email:
❑ Check if all work will be performed by homeowner only
• Contractor: Workers' Comp documentation must be submitted with this application
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _(
Email:
• En ineer s : l
Name(s): 5PG .✓ �[•��/� g5�/G.'�!L° 5> !" </1471j�64/ /%44n/ 4
/ 7
Mailing Address, C/S/Z: �I.�� /�°��h �ar', /�/r• c' 44. 3
Cell Phone: _( ) Land Line: _( 5`/f ) 71/" '
Email: /1747g44 nine '✓f.
Contact Person for Building & Code Compliance:
Cell Phone: _( ) Land Line: (
Email:
Principle Structure Packet Revised February 2019
v
Ryyyy' jyy .tee -.-..-_-.
m 1 t1 j TT
/ e9 yis
I bI/( ( MAY 1 5 2 I I
�- ,�✓pfi /..1 -/ 1"4✓ G/��i�i14 ��/1";✓i-ZZ✓/j�' I`,� ( z NS URY
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms: X gallons per =total daily flow
per day bedroom Garbage Grinder Yes 0
1980 or older 150 Installed? (circle one)
1981-1991 130 Spa or Hot Tub Yes
1992-Present 110 Installed? (circle one)
3 Ic0
PARCEL INFORMATION:
Topography I/ Flat Rolling Steep Slope %Slope
Soil Nature ,Sand Loam Clay Other(explain: )
Groundwater At what depth? > 70). 9
H
Bedrock/Impervious material At what depth? > 7,,k
Domestic Water Supply 1'Municipal _Well (if well,water supply from any septic system absorption is ft.)
Percolation Test Rate:/,O ,. per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size /,,04a 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 /4-V ft.; Each Trench i-21- 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 and 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. 3. As-built drawings must be
submitted prior to the inspection, if there has been a change to the submitted plans.
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: A7�� G74/a/?�7s,4,---) DATE: C A /
i d
,- ,
SIGNATURE: /7 'Z -` -dJ/ ` DATE: -/:9
y
Principle Structure Packet Revised February 2019
FUEL BURNING APPLIANCE & Office Use Only
11 CHIMNEY APPLICATION Permit#: �C. ' 9(Q.1k'Zplpf
Permit Fee:$ t2..5"
Town of(Zuccnshury
22/1(0
742 Bay Road, Queensbury, NY 12804 Invoice:#:
P: 518-761-8256 www.queensbury.net
Project Location: +- •sZur4.---br Tax Map ID #:
Room of Install: L\v\v-,e..‘Q.o Planned Install Date:
**ONE APPLICATION PER APP6ANt "� 3 2019 ,
CONTACT INFORMATION: TOWN OF CUEENSBURY
BUILD€ G &CODES
• Applicant:
Name(s): L A.yTh%cur-.
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: (
Email:
• Primary Owner(s): O
Name(s):
Mailing Address, C/S/Z:
Cell Phone: _( ) Lancl Li ), (
Email:
❑ Check if all work will be performed bylaomeowner only
• Installer/Builder: Workers' Comp documentation must be submitted with this application
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: (
Email:
Contact Person for Building & Code Compliance:
Cell Phone: ( ) Land Line: (
Email:
Fuel Burning Appliance&Chimney Application Revised February 2019
FUEL BURNING APPLIANCE INFORMATION:
TYPE OF DEVICE:
Stove Fireplace Insert 1 fireplace
Fuel Fired Equipment (Garage Only, 18" clearance per IMC 304.3)
Fireplace, factory built**
�, re
(**Manufacturer's name: Mt.---AJio I J4' Model #: F V 4a
SOURCE OF HEAT:
Wood Coal Pellet Gas
CHIMNEY INFORMATION:
Masonry (require plans to be submitted):
block brick stone
Flue:
tile steel size, in inches
Material*: T'
double-wall triple-wall insulated Di t2-eel jie-
(*Manufacturer's name: Model #:
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 inspections.
5. Workers' Comp insurance information is required with this application.
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: ) 1" 4 ' Oti. kiAJ &I
SIGNATURE: DATE: 1.413//9
Fuel Burning Appliance&Chimney Application Revised February 2019