applications Office Use Only
Permit#:
`' PRINCIPLE STRUCTURE PERMIT
�`'a �* APPLICATION Permit Fee:$ 1/ G'` (oo ( ?S 12.0 • lQ�
742 Bay Road Queensbury, NV 12804 *Rec. Fee: $ ' /11j.. /1VA
P 518-761-8256 Invoice#: 12-
Project Location: t2i)
Tax Map #: 2- 9 C- l S _ Z- `- N i Subdivision Name: IC tk (L NDati All) e r-)
st ti
TOWN BD RESOLUTION 86-2013 S850 recreation fee for new dwelling uni=. single family. dupx: : two-family,
multiplefamily apartments condominiums townhouses and or manufactured L mock ;t not rrrgbtrs
_:
homes. This is in addition to the permit fee(s). if-,,
CONTACT INFORMATION: ' '
2019
• Applicant:
Name(s): F o o T H l LDS TO`N OF QUEENSBURY
( ) B t,�t Crt� E RS C�0 E Leu c.t ) Crwrol IMrTY DEVE! rIPMENT
Mailing Address, C/S/Z: q fml o uN TA (NS toe: t.1tt t2.vo`
Cell Ph.: t_( c t ) 7 t t - i'l 33 Land Line: I (Sty ) 196-3SZo (Cecr~)
Email: FoOTHtrr_sBLk L.9ERS N`/ () C—mil)L. c o wN
• Primary Owner(s):
Name(s): SPrfrr ---flS fl-r�P.H-Efl*r-1 J CLtoi lAfFN ESTATES
Mailing Address, C/S/Z: S'A A D D IZES-S AS APPL/ CAN tt
Cell Ph.: ( ) Land Line: (
Email:
• Contractor(s):
Name(s): S Am€T AS A PpLk CAN-1
Mailing Address, C/S/Z:
Cell Ph.: ( ) Land Line: ( )
Email:
• Architect(s)/Enqineer(s):
Name(s): bAIJ 2Y11-1 i PE (_vlSio+-) ENG-►NEE-gliic
Mailing Address, C/S/Z: 2.00 G-LeNJ S I Sim TO 54o G-L4 '- F 12-10 1
Cell Ph.: ( ) Land Line: l (S't p ) `79 2 - 9 2 teLf
Email: 1)1Z.1 AP@ VlcIoNENG . LmfadL
Contact Person for Building & Code Compliance: 30T LPL&L l
Cell Ph.: I(S-lr ) `1`l l- (933 Eat Line: t (mot8 ) `1Q-3S20
Email: Foo iNtt.t-SGttiLi)Ct2S ,J7 C MA! L . Corv\
TnO Ruildine R Corte Fnfnrr?ment Prinrinle Structure Reviced March 201R
PROJECT INFORMATION:
TYPE: Commercial 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:
1T floor: I`! 1- L- 1sT floor: S 2--E
2nd floor: _ 2"d floor:
ra
3 floor: Total square feet:
Basement(habitable space):
Total square feet: 1 1 2Z
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ 1 7 C a O UU
2. Proposed use of the building: ZxS i 0 Ut z i A L
3. If Commercial or Industrial, indicate the name of the business:
4. Source of Heat(circle one): Gas 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 I NO,,Explain:
6. Are there any easements on the property? YES NO
7. SITE INFORMATION:
a.What is the dimensions or acreage of the parcel? O,tl t•i c.I -
b. Is this a corner lot? YES NO .
c. Will the grade be changed as a result-af=tb. construction? YES •
d.What is the water source? <.2UBLIC PRIVATE WELL
e. Is the parcel on SEWER or a PRIVATE SEPTIC system? i v
Ton Buildin¢&Corlp Fnfnrremant Prinrinlo StnrturA Rotricwi NL2rrh 7f173i
DECLARATION:
I. l 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 1.
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 1, or my agents, will obtain a
certificate of occupancy.
5. I understand that bwe are required to provide an as-built survey by a licensed land surveyor of
all newly constructed facilities priorto issuance of a certificate of occupancy.
1 have read and agree to the above:
PRINT NAME: J6SE PA LELA- Ll
SIGNATURE: fAA /DATE: 3 ( 1 I I
ToQ Building&Code Enforcement Prinrinb Rtntrtiirp RovicM Mzrrh 7f11 R
J.
, . SEPTIC DISPOSAL PERMIT APPLICA I I ON it .v use()111
7-2 Bay Road,Queenssbury, N.Y 04
P 518 76 -, 56 Perm = 2. -0 t ) to . Z.p le
Tax: Map lD#. 2--61 c . iS- 2-- )) , -rent;! -_.
Project Location: 6 S J 0 1*r C t D G N i2-D 3` ? i!
Primary Owner(s) ROTHtLLS 3 1LbERS LLC C-SO Le LA (T
Mailing Address _+-11 mbLi-NifAINS'De' 1�12 Qu.6t>-tvSBtai N,-1 y I2$Ul1 v_
Phone & Email )-
(c-1 it-(y33 /(s-(0 �19C - 3SZo__- EotTHtLLS$(AtLrbER�Ny e60►RIL,(-
Installer/Builder &Arne- AS APPLIC RNiT
Mailing Address
Phone & Email
1 Engineer TC M
-- CI:N� asP-C'
Mailing Address /( NAY l L.-AN rJ P b QLLe-e-NS A L y ti2_1 N 12.801
r Phone& Email I
( C5t )1`1G -251S TCLNTLFZ3(o@ `jAfjOv, Cbryr
Contact Person for Bulkiing&Code Comptianc�:S4� LE'&<-t 1= -zones: C510111 - ('133
RESIDENCE NFORMATION: (cif) /(o-�20
Year Built # of bedrooms X gallons per bedroom = totaidaily flow Garbage Grinder Yes No
1380 or older Installed? {circle one)
981- B91 __._.___ -_-- _ Spa or Hot Tub Yes No
1392-Present1 /to ?3 Installed? {circle one)
t D
PARCEL NFORMATION:
Topography Flat Rolling Steep Slope %Slope
Soil Nature _Sand _Loam Clay _Other
Groundwater At what depth? W. µ
Bedrock/Irnperviousmateriai : At what depth? N (A
Domestic Water Supply 2.g.Municipal _Well{if well.water supply from any septic system absorption is It.)
Percolation Test Rate "0.1--(per minute per inch{test to be completed by licensed engneer/arc1-tect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size 10 of., gallons{min-size 1000 gallons.add 250 ga lions for each garbage cylinder or spa/hot tub
System Absorption field with#2 stone Total length / S(_> ft.:EachTrench ro ft.
Seepage Pit with#3 stone How many: -Size:
Alternative System Bed or other type:
I— HoldingTank System Total required capacity? -tank size :# of tanks
NOTES:lAlarm system&associated electrica I work must be inspected bya 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: 1 D S F-f) A C E?- -/ DATE: 3 11 d +/
CI
SIGNATURE: Z/I DATE: 3//0// j>
To:•;: . OL; em.__ . t:' IC--;,Enfo-,_ement
Town ofueensb1C David Duell
Highway Superintendent
Highway 518-761-8212
Department f .
Mark Benware
42 Bay Road—Queensbury,NY
12801 `-- Deputy Highway Superintendent
518-761-8210
Phone: (518) ;61-82 1 1
Fax: (518) 745-4466 E 'ems la s E ..
DRIVEWAY PERMIT 1 -, MAR 1 1 2
DATE: J\It), I' TOWN OF 0UEENSBURY
APPLICANT NAME: s (�v,..\c ,N Wog, ' �. B I D,i9, C 9m.S
TELEPHONE NO.: � tib - _c7 k �'�Glb 52O
ADDRESS TO BE INSPECTED: la`D Cke.sr.&o.n (-cL
RETURN ADDRESS: 9 `Mo vurti'cI.A. ,
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 approved permit for a final approval.
STEP 2: ( ) Final Approval ( ) Rejected
Date:
David Duell, Highway Superintendent Mark Benware, Deputy Highway Superintendent