applications t -
. � 1---") ECEUVElifice Use Only
PRINCIPL Termit#: P—C — 6�53 F_ 619
A TION —JPermit Fee:$ ,
Town of CLeensbury
742 Bay Road,Queensbury,NY 12804 TOWN OF QUEENSBUR`/
*Rec Fee:$ g 50. 00
BUILDING&CODES
P:518-761-8256 www.queensbury.net Invoice#: L-1
Project Location: -7D ) cmon e i-Vt I\ i f
Tax Map ID#: 3D 8 7 I -71 Subdivision Name: 3Qc c r ic3r-r f'_iQn+S
*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:
Name(s): NocA cDu k t 1--,or')
Mailing Address, C/S/Z: 3cAc-clec r-nec.k-c _s, N 1 I a 30(P
Cell Phone: ( ) Land Line: (5/8 ) 356 — H-35
Email: Ceuiti krto coWSk.`c �)4= Com
• Primary Owner(s): J
Name(s): on ?jam, lAec s
Mailing Address, C/S/Z: 19(4, iu-check 3t RC-henecfac j, Al / /Q306,
Cell Phone: ( ) Land Line: (5/ $ ) 356,
Email:_faLd \o&C ow :t u_e, Corr)
• Contractor(s):
Business Name:
Contact Narne(s): cCcL
Mailing Address, C/S/Z: `7ct tp l u ec 5{ Se— nc-- cAcL INN /a30IP
Cell Phone: ( 5/S ) fps -- g®7 Land Line: (
Email: pe c hc� 2 � e rt, COM
• Architect(s) Engineer(s):
Business Name: No(--Vn5` Q( --Ir,r-Y)e:, 1-)CSioyl
Contact Name(s): okr)n I�GLZ
Mailing Address, C/S/Z: *J5 CArlec L,J Tce Lcjs � 1-1'i)f! ,
Cell Phone: ( ) Land Line: ( ,5 (S ) 3DL, 5(151
Email: 31 .,z Iq(pg YIN). cc. Corr,
Contact Person for Building & Code Compliance: 'Pep CrKt'Gi c..t
Cell Phone: ( i ) 3(,5- S8 D7 Land Line: (
Email: (1e v e g \ eAr cc l_e)SY--t e�l'`o e wry)
Town 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 units
Townhouse _Business Office Retail Hotel/Motel
Industrial/Warehouse —Garage (#of cars ) _Other(describe
SQUARE FOOTAGE: Cl aracs� ce_ 0 cA-coc
1st floor: I C0 09 I-
T' floor: 13 C)1 -+.1— 5 3/4 0 5 4-1-.
3rd floor:
4th floor:
+/,
Total square feet: aci I C)
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ abort
2. Proposed use of the building: 3,floes - 'o c j cLADAtnq
3. If Commercial or Industrial, indicate the name of the business: J
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 6) Explain:
6. Are there any easements on the property? YES
7. SITE INFORMATION:
+/�
a. What is the dimensions or acreage of the parcel? • 5
b. Is this a corner lot? YES NO
c. Will the grade be changed as a result of the construction? YES
d. What is the water source? UBLI PRIVATE WELL
e. Is the parcel on SEWER or(RIVATE SEPTIC ystem?
Town of Queensbury Building&Code Enforcement Principle Structure Application Revised February 2017
DECLARATION:
1. I acknowledge that no construction shall commence prior to issuance of a valid b u i Id i ng 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: PL \ koAc,co .,,,
SIGNATURE: �' > DATE:
•
Town of Queensbury Building&Code Enforcement Principle Structure Application Revised February 2017
FUEL BURNING APPLIANCE & Office Use Only
. ,,,,--›_
CHIMNEY APPLICATION Permit#: aG -1)2 ASS- 2_0 (9
---. .?:,,, /,
Permit Fee:$
Town of CZuccnsburn
742 Bay Road,Queensbury, NY 12804 Invoice:#:
P: 518-761-8256 www.queensbury.net
Project Location: 10 ;�cnrnc 4,r\ Ik-Tax Map ID #: 3 0 8 1 - f --1(
Room of Install: 1 cam,; 1,•`�hoc Planned Install Date:
**ONE APPLICATION PER APPLIANCE**
CONTACT INFORMATION:
• Applicant:
Name(s): \-kocaorr oc,, \--kornes
Mailing Address, C/S/Z: 19(4> `)LtrckeMC St 3 c.t-t-enecfaeLc3, NY /a 3b(D
Cell Phone: I ) Land Line: (518 ) ,356, - i4 35
Email: ('fat Ili (j inoc6c-cat :,\(►`'ne enec . C_orn
• Primary Owner(s):
Name(s): ( V‘SS'ion -6Lti Ickr
Mailing Address, C/S/Z: -101 -c ec L fleck.- d NY / 3 �
Cell Phone:_( ) Land Line: _(,5`t g ) 35& - /y-35
Email: kc \ ce hr,ckb,c-r)k nke..:Ac cr->tl awn
• Installer/Builder:
Business Name: \ \cok.a k., 40m''nes
Contact Name(s): Qe Ce cccx c\'s
Mailing Address, C/S/Z: 7q 6 Buzracct. 5L. , clie-ne c ctc + N\I ( 3b(a
Cell Phone:_(5i 8 ) 5(.05- 8iS b1 Land Line: ( )
Email: ?PTV_ \n0Aoco coS -\c ou a LOCI)
Contact Person for Building & Code Compliance: 'Pe.p i
CD(fac
Cell Phone: ( 5 i g ) 36,5- $L1 Land Line: ( )
Email: g. ‘r o<k(:)COI TA..,TDt.a , eorn
Fuel Burning Appliance &Chimney Application Revised March 2017
FUEL BURNING APPLIANCE INFORMATION:
TYPE OF DEVICE:
Stove Fireplace Insert Fireplace
_ Fuel Fired Equipment (Garage Only, 18" clearance per IMC 304.3)
Fireplace,factory built**
**Manufacturer's name: j,a r c c- Model#: DP, o O35
SOURCE OF HEAT:
Wood Coal _Pellet as )
CHIMNEY INFORMATION: Gc,g CV+ce6 ex-
Masonry:
block brick stone
Flue:
_ ^tie steel size, in inches
Material*:
double-wall triple-wall insulated
(*Manufacturer's name: Model #:
ADDITIONAL INFORMATION:
1. Two inspections are required. A rough-in inspection, prior to installation and a final inspection, after
installation.
2. Manufacturer's installation manual must be available at the time of inspection.
3. Masonry fireplaces &chimneys require plans to be submitted.
4. Twenty-four(24) hour notification is required for inspections.
Declaration:Construction/installation must conform to NYS Fire Prevention &Building Code and/or manufacturer
requirements. The applicant or owner agrees to comply with all applicable laws,ordinances, regulations and all
conditions that are part of these requirements and also will allow the inspector to enter the premises to perform the
required inspections.
I have read and agree to the above:
PRINT NAME: C) \ C os T
SIGNATURE: DATE:
Fuel Burning Appliance &Chimney Application Revised March 2017
' _
SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
T i 742 Bay Road,Queensbury,NY 12804
r,,„of{�`r sb ry P:518-761-8256 www.queensbury.net Permit#: '(2C.-0 2- -20 <\
Tax Map Id#: 3 CA.
� — Permit Fee:$ ; Invoice#:
�
Project Location: 1 0 - (hm on(4 lAt' `( )n‘l , Septic Variance? Yes No
Primary Owner(s) i 55 i o(-1 13w \A-ex--
Mailing Address 7gle accr8e-c, Sk. ern kciA 101 I.a.36(,n
Phone& Email es�Pc_
51$ - 35C, 14135 .mot a \nockc o s Cyrok-oV, C,Cacr)
Installer/Builder IA vc ocbk > ‘, tiCe'
Mailing Address 196 gLirckeGk t )r)enectaC a ` Nu /A30
4
Phone & Email 5/g - 35C0- /L66 en ,.0 a 1oislc,„,: k.. cce,u, com
Engineer Van 'DU Se- et" 3-4 e\fe Lac)CJ 3t,e_e " o C5
Mailing Address [CPq New d (u`..)J -p 8,
Phone& Email ,5 jgg- 7q 9 - 84--14 /t
Contact Person for Building&Code Compliance: Pee Cbcco.c ( Phone: 5 I g- 1 5-g 8e,7
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
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 _Municipal _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 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 ft.; Each Trench 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. 1\C'PRINT NAME: Pcu. \ �OCCbt t) 4 DATE:
SIGNATURE: DATE:
Town of Queensbury Building&Code Enforcement Revised February 2017