applications r
Office Use Only
Permit#: OO ,2- -20‘9
PRINCIPLE STRUCTURE PERMIT
Permit Fee:$
APPLICATION
T nsbury *Rec Fee:$ A p ,r-1\Pr- �ric\t i
742 Bayy Road,Queensbury,NY 12804 ` J
P:518-761-8256 www.queensbury.net Invoice#:
Project Location: Li_Z (.Q 1 C \) S
Tax Map ID #: 9( `' — 1 — Subdivision Name:
*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:
Mailing Address, C/S/Z: (,, \
Cell Phone: ( ) Land Line: ) •' 7
Email:
• Primary Owner(s):
Name(s): C ��
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: ( )
Email:
• Contractor(s):
Business Name:
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: - (
Email:
• Architect(s)/Engineer(s):
Business Name: �-- '
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: (
Email:
Contact Person for Building & Code Compliance:
Cell Phone: (``)‘`E) L ( - = Land Line: (
Email:
Town of Queensbury Building&Code Enforcement Principle Structure Application Revised February 2017
PROJECT INFORMATION:
TYPE: Commercial ",, Residential
WORK CLASS:
Single-Family Two-Family Multi-Family(#of )
Townhouse Business Office Retail Hotel/Motel
_Industrial/Warehouse Garage(#ofcars ) Other(describe )
STRUCTURE SQUARE FOOTAGE: GARAGE SQUARE FOOTAGE:
151.floor: C,' 1sT floor: 5-1 -
2"d floor: 2nd floor:
3'floor
Total square feet: '5 7(e.
4th floor:
Total square feet:
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ t LI 0
2. Proposed use of the building:
3. If Commercial or Industrial, indicate the name of the business:
4. Source of Heat (circle one as ) Oil Propane Solar Other:
(Fireplaces need a separate Fuel Burning Appliances & Chimney Application, one per appliance)
5. Are there any structures not shown on the plot plan? YES NO plain:
6. Are there any easements on the property? YES 0
7. SITE INFORMATION:
a. What is the dimensions or acreage of the parcel? `r7 a 4 ( •d (a-
b. Is this a corner lot? YES NO
c. Will the grade be changed as a result of the construction? YES 0
d. What is the water source? IC PRIVATE WELL
e. Is the parcel on SEWER r a PRIVATE SEPTIC tem? '
Tavn o`Queensbury Buitddrxd&Cade Enforcement Principle Structure App cation Revised February 2017
DECLARATION:
I. 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: \ rat=;
SIGNATURE: . ' -' ",=, DATE: 11,.7 Mt
z:///
Town of Queensbury Building&Code Enforcement Principle Structure Application Revised February 2017
SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
742 Bay Road,Queensbury,NY 12804
.rtgcc•n rain P:518-761-8256 www.Queensbury.net Permit#: �G—D 2- ' 2-0 \O1
Tax Map ID#: (� t, r`� I I Permit Fee:$ ; Invoice#:
Project Location: Septic Variance? Yes No
Primary Owner(s) kv
Mailing Address
Phone & Email
Installer/Builder C
Mailing Address
Phone & Email
Engineer
Mailing Address
Phone & Email
Contact Person for Building&Code Compliance: Phone: NZA
RESIDENCE INFORMATION:
Year Built #of bedrooms X gallons per bedroom =total daily flow Garbage Grinder Yes l"No1
1980 or older Installed? (circle one)
1981-1991 Spa or Hot Tub Yes No
Installed? (circle one)
1992-Present k
PARCEL INFORMATION:
Topography Flat Rolling Steep Slope %Slope
Soil Nature )Sand Loam Clay Other
Groundwater At what depth?
Bedrock/Impervious material At what depth?
Domestic Water Supply sunicipal _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:
Tank size '\Cc O 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 1 "7 v ft.; Each Trench ` C: 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: DATE: 1 �� h 4-7
SIGNATURE: "ice DATE:
Town of Queensb _Building&Code Enforcement Revised February 2017