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PRINCIPLESTRU
APPLIC e i e $_ °,S Gt 0
JAN 2 8 20 9�
742 Bay Road Queensbury, NV 12804 R c. ee
P 518 76 i 8256 ..- TOWN OF QUEE S U �( U
% BUILDING&C el e# 1 Z 3
Project Location: L_bT C s-tji)0
Tax Map Subdivision Name: a6 NN CtCN1Dbd
TOWN BD RESOLUTION 86-2013 S850 recreation fee for new dwelling um.; single family: dupfe x s two-family,
multiple family. apartments condominiums tosvnhou,es.and=or manufactured �L modular homes but not mobie
homes. This is in addition to the permit fee(s).
CONTACT INFORMATION:
• A1212licant:
Name(s): o d T H i l�S 9 Lk I Ll tr r2S CSU c LEkA c.-1
Mailing Address, C/S/Z: M 0 U/J TA (NS I D C bP•I ve OukoePs!f .Qy fiv 12-ro y
Cell Ph.: i -1 I t - l91 33. Lie:
I
Email: F'oo tl{1c�SB�a� 1✓�ERs �.ty C-mA1�. ca r✓�
A.
® Primary Owner(s): i
Name(s): SAmE AS A PPt-I C At4T `
Mailing Address, C/S/Z:
Cell Ph.: _(') Land Line:
N
Email:
• Contractor(s):
Name(s): S n(n'F- AS A P P L1 C(AN-T
Mailing Address, C/S/Z:
Cell Ph.: —{-�-)- Land Line: �(_)
Email:
• Arch itect(s)/Engineer(s):
Name(s): 'I)A tJ M A t e , f E CV I S I 0 tJ F NG 1 N E-6 9'1N C )
Mailing Address, CIS/Z: 20 o G-LGN 5 i SuiTC' 5 9 Gt_ENs FAL-Ls N `f 1 no
Cell Ph.: _( ) Land Line: I (_EL?
Email: -t (L11AN- YISIyNENt;, e M A L
Contact Person for Building & Code Compliance: Joc L61�L I
Cell Ph.: ( (TIV ) -111- (133 L-aff.d Line: i 1 q . 3S-2.0 LE`er
Email: F6cTNtLLS �u�r {rr�Ct251�y� C Mf11L C.a
TnO nuildine P,C'ndP Fnfnmf-mPnt PrinriniP SfmrrurP RPA,;Prf Marrh 20I R
PROJECT INFORMATION:
TYPE: Commercial Residential
WORK CLASS:
Single-Family Two-Family _Multi-Family(#of )
Townhouse Business Office Retail Hotel/Motel
�IndustriaUWarehouse Garage(#ofcars �} Other(describe. }
STRUCTURE SQUARE FOOTAGE: GARAGE SQUARE FOOTAGE:
isT floor:__1y 2-1, i5T floor: , S 17
Znd floor: Znd floor:
31floor: Total square feet:
Basement(habitable space):
Total square feet: N 2-2-
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$ l �—b 16D 0
2. Proposed use of the building: RES I D wT i A L
3. If Commercial or industrial, indicate the name of the business:
4. Source of Heat(circle one): 95Oil Propane Solar Other:
(Fireplaces need a separate Fuel Burning Appliances&Chimney Application,one per appliance)
S. Are there any structures not shown on the plot plan? YES N�xplain:
6. Are there any easements on the property? YES
7. SITE INFORMATION:
a.What is the dimensions or acreage of the parcel? D o A C�LS
b. Is this a corner lot? YES N
c. Will the grade be changed as a res a construction? YES O
d.What is the water source? PUBLIC PRIVATE WELL
e. Is the parcel on SEWER or a PRIVATE SEPTIC system? P9_j v-A TCr
TnO Ruildina R CAdP Fnfnrtamanr Prinrinla Gtnirhara Ravkad Marrh MIR
i
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 1year expiration date the permit may be renewed,
subject to fees and department approva I.
1 1 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 1oc W zoning
regulations.
4, 1 acknowledge that prior to occupying the facilities proposed I, or my agents, will obtain a
certificate of occupancy.
5. 1 understand that We are required to provide an as-built survey by a licensed land surveyor of
ail newly constructed facilities prior to issuance of certificate of occupancy.
I have read and agree to the above:
PRINT NAME: o S C P 14 LC L4 �
SIGNATURE: r DATE: Z�
Too Buildine&[ode Enforcement Prinrinlp%tnirtiirp Ravicarl Myrrh 7niR
Office Use Only
FUEL BURNING APPLIANCE cQ Permit#: Q,G-•�p1��j •Zp�
CHIMNEY APPLICATION
Permit Fee:$
Invoice #:
6 iy Road, Queensbu- N`, -2804 P:
516 761-8256
Project Location: _(Q ( 3a (I Lt=-u D6 N Tax Map ID:
Room of Install: _ Qr-ReA-V Planned Install Date:
**ONE APPLICATION PERAPPLIANCE**
CONIACT INFORMATION,°
Applicant:
Name(s): Fo o i't-1 I LL s 6 ck t LL e P.S LLC ( Jot LC u C 1)
Mailing Address, C/S/Z: 9 QugLNs/g+n��1
Cell Ph.: 1 19 1- Ig 3 3 L Line: ( C �)
Email: FOO KlU- P)(Al(.,t)ER3N`( (�) C—.M(1)L, c6rrn
O Primary Owner(s): —
Name(s): S'p m-c- r)s t)PrL I c A.N 1
Mailing Address, C/S/Z:
Cell Ph,: _�� Land Line:
Email:
® Installer/Builder:
Name(s): S 19 mIG- ()s p P z i c.r-
Mailing Address, C/S/Z:
Cell Ph.: _( ) Land Line:
Email:
Contact Person for Building & Code Compliance: 3o0 L-EV,C I
Cell Ph.: (( ( t 4( 3 3 Lmi4 Line: 1 5'1 S' 116 - 3s2.0 LcCfc
Email: �u� �� ',� � Foo &/LILbE9-SNV d G-MA)L, c4rv,
1%vno'Ou_ensbury ewldin-
FUEL BURNING APPLIANCE INFORMATION:
TYPE OF DEVICE:
Stove Fireplace Insert _Pireplace
WNI lC I�'1Ckr-ilrl1N Shope-L_ DVj) 3& F'P3oN
—Fuel Fired Equipment(Garage Only,'B"clearance per IMC304.3)
`Fireplace, factorybuilt**
**Manufacturer's Name: Model#:
SOURCE OF HEAT:
Wood Coal Pellet Gas
CHIMNEY INFORMATION•
_-Masonry:
block brick stone
Flue;
size,in inches
tie �te e I
Material':
double-wall triple-wa II—insulated
("Manufacturer's Model#.
ADDITIONAL INFORMATION:
9- 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.
Declarati=-Constructionrinstallation 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
conditionsthat are part ofthese requirements and also will allow the inspector to enter the premises to perform the
required inspections.
have read and agree to the above:
PRINT NAME: E P H Le" c,I
SIGNATURE: V \, I ®^-T"FEE
- I Z(p
Fuel Burning Appliance&8himney Application
. ^
'
°
SEPTIC DISPOSAL PERMIT APPLICATION Office Use 00
Tax Map ID#.: 12- Permit
Project Location: Y_
Xb
Primary Owner(s)
Mailing Address I-J
Mailing Address
Phone & Email
'
Engineer
Mailing Address
Phone & Email
RESIDENCE INFORMATION:
Year Built #of bedrooms X gallons per bedroom otal ill flo Garbage Grinder es
Installed? (circle one)
1980 or older,
Spa or Hot Tub Yes UN
Installed? {circle one)
PARCEL INFORMATION:
--Groundwater At what dep,ih.
Domestic Wateri�u_pply
Municipal _ Well fif well,water supply from any septic system absorption is_ ft.)
Percolation Test 1 Rate: per minute per inch{test to be completed by_11censed en�heedarcHect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size t 0 0 0 gallons{min.size 1000 ga_lions,add 250ga lions for eachigarbage cylinder or spa/hot tub
system Absorption field with#2 stone ,;Total length /IS Z) ft.;EachTrench S-6 It.
Seepage Pit with#3 stone ?How many: Size:
Alternative System Bed or other type:
HoldingTank System Total required capacity? -tank size :# oftanks
NOTES: 1.Alarm system&associated electric@ lWork must be inspected bya Town approved electrical inspection
agency:2,We will no longer allow systerns to becovered untilsuch timeasain as-bLliltpl2n is received andapproved.
The installed system must match the septic layout on file-no exceptions.
DeclarationAny permit or approval granted w hich is based upon or is gra nted in reliance upon any m@terial
representation or failure to make a material fact or cirCLimstance known by or on behalf of an applicant. shall be void.1
have read the regubtions and agree to abide bythese and all requirements of the Town Of QUeensbUry Sanitary Sewage
Disposal Ordinance.
PRINT NAME: J65 CE P [A Lirt-CL Cl DATE: /0
SIGNATURE: Ad
7
DATE:—� � /
Town of Queensbury 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 Dueii
Deputy Highway Superintendent
Home:518-745-0938
DRIVEWAY PERMIT
Date: 2(pLJ
Applicant Name: FOo M t U S Lt LDc S u C(>
Telephone No.:
Address to be Inspected: (p j T6 H N C L-EN D -N (-D
Return Address: Ira K N Z'fa 1 N S IyE De-
6 l" 2/Z iv`i 1 2 3-6 1
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