applications s.,
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• CC) \11 E. l• . Office Use Only
PRI PIC TC ,(F PE Permit#: CC O rS "` of
� ILE .F[1Rl
L UD, a0
L• RLIcAT.IONJ Permit Fee:$ 3
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T C)i r' bra OlUEENS BU RY *Rec. Fee:$
742 Bay Road, Queensbury, N / -28o4` UILDMG COo) 6
P: 518-761-8256 www queen,bury nei Invoice#: 0 LI 7iLf
Project Location: 7S '-t �O4
Tax Map #: (2)Oq .2-0 — f` 3r 3 Subdivision Name: CAteVf ,ep�4D
TOWN BD.RESOLUTION 86-2013:$850 recreation fee for new dwelling units: single family,duplexes/two-family,
multiplefamily, apartments,condominiums townh_ouses,and'or manufactured & modular homes,but not mobile
homes. This is in addition to the permit fee(s).
CONTACT INFORMATION:
• Applicant:
Name(s): .�_ (,EJ S1P--cio or
Mailing Address, CIS/Z: 72& GNU ���-�iT' 5 �/iJ FbY NLi !Z_Q47
Cell Ph.: _( _37 3/ Land Line:_( t578 ) SS-G-(4,,5S
Email: et472 C J b 0-0(.05 647 p,60
• Primary Owner(s):
Name(s): `coAlivo L
Mailing Address, C/S/Z: PO 60K M &D E5 NY 1ZO47
Cell Ph.: ( ) Land Line: (5-75) 7-38' Ao Z
Email: /44(KEepek L ; JEI '. Oorkx
• Contractor(s):
Name(s): .L / Ace coNcnevere4
Mailing Address, C/S/Z: 77(.0 s(EirV€TCt/9-bie AP( l Z.-so cc
Cell Ph.: ( ) Land Line: ( 5 Cf) ) 3S 6,—/43.S---
Email: ( el 040.(;)0eDl.05ki67090, cow%
• Architect(s)/Engineer(s):
Name(s): P=W•t.(SP-OUQ &(
Mailing Address, C/S/Z: 13 ? V1CH- 2 FeRge ice, H t-F/14ct A( 1 7-0605
Cell Ph.: _( 570) r Land Line: _(,SZe7) (0 8? 7-
Ema il: Pit iv t DE (C�i cI cup eppt►�-(L-- 60,4-N
Contact Person for Building & Code Compliance:
Cell Ph.: _( 579) 540— 3731 Land Line:_( 33
Email: fi¢T-LC( •AO/?oWSt-t cgo92. Com
Tnr)Building R Cnde Enforcement Princinle Structure Reviser!March 2)1 R
PROJECT INFORMATION:
TYPE: a" Commercial Residential
WORK CLASS:
Single-Family Two-Family _Multi-Family(#of )
Townhouse X Business Office Retail Hotel/Motel
_Industrial/Warehouse Garage(#of cars ) Other(describe )
STRUCTURE SQUARE FOOTAGE: GARAGE SQUARE FOOTAGE:
1ST floor: `Zj 7JQ 1sr floor:
2nd floor: 2nd floor:
3rd floor:
Total square feet:
Basement(habitable space):
Total square feet: 1 Z(
•
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$ 4 7411 1 r1
2.' Proposed use of the building: ®FF( i Gtisf} (cUSE
3. If Commercial or Industrial,indicate the name of the business:
4. Source of Heat(circle 4one) Oil Propane Solar Other:
(Fireplaces need a separat Burning Appliances&Chimney Application,one per appliance)
S. Are there any structures not shown on the plot plan? YES P..) plain:
6. Are there any easements on the property? YES 0
7. SITE INFORMATION:
a.What is the dimensions or acreage?...the parcel? 1,60 Ae
b.Is this a corner lot? YES 10
c. Will the grade be changed as a resu t e construction? 41010 NO
d.What is the water source? PUBLI PRIVATE WELL
e. Is the parcel on SEWER or a PRI SEPTIC system? -
Tn(1 Buildirm R.COdp EnfnrrPmPnt Prinrinlu Ctrurturw RwvicPd March 701R
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 1 year 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 Uwe 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: ��
f1
SIGNATURE: ekilaCr-1`P DATE: 5111`43
ToO Building&Code Enforcement arintinla ctr,lr?nrP RP„ieprl Marrh 7mu
„::rr SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
TOW)of L3 742 Bay Road,Queensbury,NY 12804
2ccQsi"`ry P:518-761-8256 www.queensbury.net Permit#:
Tax Map ID#: 3PE3,20—L—3 g-3 Permit Fee:$ ;Invoice#:
Project Location: 15-f (( i&4t' Septic Variance? Yes No
Primary Owner(s) O .(E Pgo 2 -t-
Mailing Address PO 60{C t2 4 PUY /2o47
Phone&Email 'Ye 2'38— t e 6-e di-Ce to of • ti.60nA
Installer/Builder ,,,, , i e CoOSrP.ve't 0
Mailing Address I oQ ,.. T'. (1,C- (-ANfi NY jZ X
Phone&Email 52 a - z/-/A-bs- PATPATP4614{0_1(013,6Atu,stA” Up•doirt
Engineer tigA& `<I EA6ove8gt/061,
Mailing Address Z467-- 5 ' -ugaits- ¶ ()trE- i fr11 4C-' /11 ' /ZcaC3
Phone&Email AGE, 8141 5Z45 .L,3t-i"ipe ,NlI�Situ6,t ',t�tx- ,.Cofr't
Contact Person for Building&Code Compliance: P1CIC-14 Phone: 5-te--Z5`373q
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms X gallons per =total daily flow ,.., .
per day bedroom Garbage Grinder Yes io)
1980 or older 150 Installed? (circle one) ---_
.1981-1.991 130 - Spa or Hot Tub Yes ILio
1992-Present 110 Installed? (circle one)
PARCEL INFORMATION:
Topography Flat Rolling Steep Slope %Slope
Soil Nature Sand Loam Clay Other
Groundwater At what depth? 1VnAJ
Bedrock/Impervious material At what depth? ji(.A- .
Domestic Water Supply k,Municipal ____Well(if well,water supply from any septic system absorption is ft.)
Percolation Test Rater?SCE p r-m tr p -,ne;(test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size 100 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 ez._ ft.; Each Trench Z ft.
Seepage Pit with#3 stone How many: 3 ;Size:
Alternative System Bed or other type: t)( 4� u tett.t -it.
Holding Tank System Total required capacity?A 3 ;tank size (64C) ;#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: pm-per- DATE: Ot/�(16
4.
SIGNATURE: J/ / � j •
DATE: e.4/15
Town of Queensbd Building&Cod nforcement Revised March 2018