applications t Office Use Only
tr--
. , . Permit#: M.^a •2-Qt$
i PRINCIPLE STRUCTURE PERMIT
-se-- f" Permit Fee:$ 1152.yam
-�-- APPLICATION
Town of Queensbur eQ
742 Bay Road,Queensbury,NY 12804 *Rec Fee: $
P:518-761-8256 www.queensburv.net Invoice#: b 563
•
Project Location: C €T-[1 ff 17106 M
Tax Map ID Th 2a0. - I- Z. Subdivision Name: Ric—lard- /I'zA s,(4. CL/.
Sk-'
*TOWN BD.RESOLUTION 86-2013: $850 recreation fee for new dwelling units: single family,duplexes/two-family,
multiple family, apartments, condominiums,townhouses, and/or manrafacture-d-&-mod 1-r o es b t not mobile
homes. This Is In addition to the permit fee(s). E C '(I
CONTACT INFORMATION: H JUN 2 5 2018
• Applicant: TOWN OF QUEENSBURY
Name(s): 5 O1?L3 IE'l lli BUILDING&CODES
Mailing Address, C/S/Z: CH-FOTh3at' Izi1 S r-�b Otree)/1,St3Ort.� . ° 12f3O'
Cell Phone: ( a Ij ) 572 �vs Land Line: ( )
Email: 11E10)a° 1-cdTMHib. con
• Primary Owner(s):
Name(s): aFeya6E $ LIZ RI-t it1 ,ir
Mailing Address, C/S/Z: (,H Tk1ut' i.e.,or4g. tcb . l (ye %T3o rc ,1<3\c` 17) t79-
Cell Phone: ( Q i'4 $) 22-7- S'O 0 Land Line: ( )
I Email: tilLT l01 t.401l-1IRtL,.C,bifl
• Contractor(s):
Business Name:
Contact Name(s): (3 o1n IZ1a'i13
Mailing Address, C/S/Z: GHi l.�oi mion 1 b , novIS'E tA k1( 1 ' 1
Cell Phone: ( q t hl )S'-y 2.vp5 Land Line: ( )
Email: (t)n(t_(ot € l..h t^,{ ,t... •COfl'-1
• Architect(s)/Engineer(s):
Business Name:
Contact Name(s): HICI-t1 L .1 . SA--P,tz€i=
Mailing Address, C/S/Z: -3/6 ACKimTLrOwl..1 Mb. 61-ti cTk)UT Tr 1 D& j kV( I q 2-
Cell Phone: ( ta4:, ) gig- toio Land Line: ( )
Email: tvu,c,ttxgc.S6f{Ae1C4' Vac ttAA.p-SCI-1-Ptyze .COYr
Contact Person for Building & Code Compliance: Qleb 01e, Rile-in
Cell Phone: ( 11 '+ ) C2,7-zoos" Land Line: ( 5, ) 61'9-6 72-5 r
Email: 1 OCti, iO l t tinAil--- tQtY
fawn of Queensbury Building&Code Enforcement Principle Structure Application Revised February 2017
,, ...,, ,,
PROJECT INFORMATION:
TYPE: Commercial V 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:
1ST floor: 2t1U • 1ST floor: tall
2'floor: SS I 2'floor:
3rd floor: Total square feet: (i1
4th floor:
Total square feet: 21 if 1 •
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ ,320,0(0o
2. Proposed use of the building: SNQ.. F 4'.i L1j
3. If Commercial or Industrial, indicate the name of the business:t
4. Source of Heat (circle one): as Oil Propane Solar Other:
(Fireplaces need a separate uel Burning Appliances&Chimney Application, one per appliance)
5. Are there any structures not shown on the plot plan? YES 0 Explain:
6. Are there any easements on the property? YES 0
7. SITE INFORMATION:
a. What is the dimensions or acreage of the parcel? 3.00 46
b. Is this a corner lot? YES
c. Will the grade be changed as a result of the construction? dp ' ,,-
d. What is the water source? PUBLIC PRIVATE 'atriP
e. Is the parcel on SEWER or a PRIVATE SEPTIC system? pJ
Town of Queensbury Building&Code Enforcement Principle Structure Appkation Revised February 2017
i' " •
DECLARATION:
1. 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 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 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 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 agree to the above: •
PRINT NAME: G,orcc
SIGNATURE: I DATE: 20 10
Town of Queensbury Building&Code Enforcement Principle Structure Application Revised February 2017
FUEL BURNING APPLIANCE & office use only
CHIMNEY APPLICATION Permit#:
Permit Fee:$.
Town of Q icensbuiy
742 Bay Road,Queensbury, NY 12804 Invoice:#.
P: 518-761-8256 www.queensbury.net
Project Location: CReSTMOT I O6 P b Tax Map ID #: 2Qa - I
Room of Install: Fikvituit Planned Install Date: 61( 1)k;
**ONE APPLICATION PER APPLIANCE**
CONTACT INFORMATION:
• Applicant:
Name(s): 6'5C1r?..I�s ti 1
Mailing Address, C/S/Z: trig' E t (9(7f-e S-6Ofl , 1.3r. (7-g rem
Cell Phone: ( Old ) S-2 z6 Land Line: ( )
Email: 1Wc, 1O(C kOTrfAtL.c,Ar
• Primary Owner(s):
Name(s): COd1G 62, RwE.11J JY
Mailing Address, C/S/Z: C1 ES -0LO- 0IPa '61 513UYi1 >lQr 12464
4
Cell Phone:_(q la ) c2i2 ?%JO Land Line: _( )
Email: IOC t,1.61i2_ Poi7TrfPetL•C D rrA
• Installer/Builder:
Business Name:
Contact Name(s): nefoytiej
Mailing Address, C/S/Z: C,l-tC'�t,a [?.ILY, Tel:) Ou eilSOUi►'� �� 12-zb
Cell Phone: _( q ) �'2�'Za 2,00 Land Line: _( )
Email: (Uc\. l I (4671YlAIL-. GO►may
Contact Person for Building & Code Compliance: m(6,12 .tv\
Cell Phone: _( 114 ) 7A 7,,`aj. Land Line: ( 'ct ) `7 7,�,S—
Email: 14.4e loi( drn IL . c, rn
Fuel Burning Appliance&Chimney Application Revised March 2017
r FUEL BURNING APPLIANCE INFORMATION:
TYPE OF DEVICE:
Stove _Fireplace Insert \ Fireplace
Fuel Fired Equipment (Garage Only, 18" clearance per IMC 304.3)
Fireplace,factory built**
**Manufacturer's name: ltk -Rk..\ Model#: �� lowk
SOURCE OF HEAT:
Wood _Coal _Pellet \ Gas
CHIMNEY INFORMATION:
_Masonry:
block brick stone
_Flue: �r
_tie \ steel 1 size, in inches
Material*:
double-wall triple-wall insulated
(*Manufacturer's name: alkr-- E-1, Model#: in) t`7 (DO )
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 inspections.
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: ' f()Ir-c.49, R,AEIt PI
SIGNATURE: � �.
DATE: C4 2Q(tg
•
Fuel Burning Appliance&Chimney Application Revised March 2017
P SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
742 Bay Road,Queensbury,NY 12804
Town of Q eersbuzy P:518-761-8256 www.queensbury.net Permit#:
Tax Map ID#: 290.-1-22.8 Permit Fee: $ ; Invoice#:
Project Location: CHESTNUT RIDGE ROAD Septic Variance? Yes No
Primary Owner(s) GEORGE RHEIN
Mailing Address 9 BIANCA COURT,WARWICK,NY 10990
Phone & Email 914-522-2005
Installer/Builder Ci- IBISClz.AMOk L.
Mailing Address
Phone & Email 510 4-70 4/ q4-
Engineer HUTCHINS ENGINEERING-TOM CENTER
Mailing Address 169 HAVILAND ROAD,QUEENSBURY,NY 12804
Phone & Email 518-796-2515 TCENTER36@YAHOO.COM
Contact Person for Building&Code Compliance: GEORGE RHEINE • Phone: 914-522-2005
RESIDENCE INFORMATION:
Year Built #of bedrooms X gallons per bedroom =total daily flow Garbage Grinder Yes No
1980 or older Installed? (circle one)
1981-1991 Spa or Hot Tub Yes No
Installed? (circle one)
1992-Present 3 110 330
PARCEL INFORMATION:
Topography Flat Rolling Steep Slope 14.1 %Slope
Soil Nature ✓ Sand ✓ Loam Clay Other
Groundwater At what depth? NONE
Bedrock/Impervious material At what depth? NONE
Domestic Water Supply _Municipal /Well (if well,water supply from any septic system absorption is 120 ft.)
Percolation Test Rate: 11 per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size 1000 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 220 ft.; Each Trench 55 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: GEQRGERHEIN DATE: 6/22/18
if
SIGNATURE: `tk
Town of Queensbury Building&Code Enforcement Revised February 2017
y } Y
' Town of Ctueeiisbuiy Thomas R.Van Ness
Highway Department Highway Superintendent
742 Bay Road,Queensbury, NY 12804 Home:518-745-0929
Phone: 518-761-8211
Fax:518-745-4466 David Duel!
Deputy Highway Superintendent
Home;518-745-0938
DRIVEWAY PERMIT
Date: (tZ e
Applicant Name:
Telephone No,: 9 t 4 5 -i ZOOS-
Address to be Inspected: OV1'Psinkst 1Z,D
Return Address;
Applicant must show exact location and width of driveway(s)to be connected to the highway by placing stakes
at the specified location.
The Superintendent of Highways of the Town of Queensbury has reviewed this application. The following
action has been taken:
STEP 1: ( ) Preliminary approval
NEED ( ) Slight Swale
( ) Deep Swale
( ) Level with the road
( ) Level with the top of the paved wing •
Size culvert pipe to be used (if necessary)
( ) 12" ( ) 15" ( ) 18" ( ) 24" ( ) 36"
Preliminary inspection completed by: Date:
Approval by Highway Supt.: or Deputy Supt.:
Upon completion please resubmit this approval permit for a final approval.
STEP 2: ( ) Final Approval ( ) Rejected
Date:
Thomas R. Van Ness, Highway Superintendent David Duell, Deputy Highway Superintendent
Town of Queensbury Building&Code Enforcement Principal Structure Application Revised February 2017