applications PRINCIPAL STRUCTURE APPLICATION Officeoffige u
DATE 2 °I tip Received�r�
�r Tax Map
TAX MAP ID �" I I I?T ' 2 ' �� Permit No.
Permit Fee (I
ZONING G L Rec Fee
Site Plan#
HISTORIC SITE _Yes No Subdivision#
SUBDIVISION NAME 01A Lot#
TOWN BD. RESOLUTION 86-2013: $850 RECREATION FEE FOR NEW DWELLING UNITS, INCLUDING SINGLE FAMILY DWELLINGS,
DUPLEXES OR TWO FAMILY DWELLINGS, MULTIPLE FAMILY DWELLINGS, APARTMENTS, CONDOMINIUMS, TOWNHOUSES, AND/OR
MANUFACTURED&MODULAR HOMES, BUT NOT MOBILE HOMES. THIS IS IN ADDITION TO THE PERMIT FEE.
APPLICANT 17'6G A;t-Q N)04im 0,AVNEP. 1/7�'JL/�t^)
ADDRESS _y7 RJL�}T)U� ✓�l� ADDRESS -I ClAaf Z YwA�
lu ®Ve�aaI+"�ti ,u�uA
PHONE/E-MAIL PHONE/ E-MAIL
" �/I �¢, - j wtGGOr`X41 t gyp'
CONTRACTOR GiAyjo YWOl d COST OF CONSTRUCTION(ESnMATED): $ 6,aAa
ADDRESS: (a,4 )9 /A &),4at, AL)e, • BUILDING ADDRESS: zRWBiY q0,A r7
PHONE/E-MAILI L�
CONTACT PERSON FOR BUILDING & CODES COMPLIANCE: �Lt�lla/11219 V 91j" PHONE:&;
TYPE OF CONSTRUCTION
Check all that apply Please indicate measurements as required below
New Addition Alteration 1 s'floor sq. ft. 2"'floor sq. ft. Total sq.ft. Height
Single Family
Two-Family
Multi-Family
(#of units )
Townhouse
Business Office %7J,
Retail - Mercantile
Factory- Industrial
Attached Garage
(#of
Other
i
Town of Queensbury Building&Codes Principal Structure Application July 2014
If commercial or industrial indicate name of business 1A)"I 116
Proposed use of building or addition kid
Source of heat (circle one) Ga it Propane Solar Other
Fireplace: complete a separate application for Fuel Burning Appliances &
Chimneys A
Are there structures not shown on plot plan? D
Are there easements on the property? O
Site Information
a. Dimensions or acreage of lot p,(� A
b. Is this a corner lot?
c. Will the grade be changed as a result of construction Yes No
d. Public water or Private well J/!j�j�(� a—ZIP-
a. Sewer or Private Septic System /,b r_
Value of all work to be performed (labor or materials) $ d O Up
DECLARATION:
1. 1 acknowledge no construction shall be commenced prior to issuance of a valid permit and will be completed
within a 12 month period.
2. If work is not complete 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 / description of
the work proposed, that all work will be performed in accordance with the NY State Building Codes, local
building laws and ordinances, and in conformance with local zoning regulations.
4. 1 acknowledge that prior to occupying the facilities proposed, I or my agents will obtain a certificate of
occupancy.
5. 1 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.} t
I have read and agree to the above: PRINT NAME: CJ&1)P(V-l�f v Ur° DATE L
SIGNATURE: o✓ DATE IL L
FOR OFFICE USE ONLY
Operating Permit Issued: _Yes _No
Occupancy Type
Construction Classification
Assembly Occupancy Limit
Special Conditions
2
Town of Queensbury Building&Codes Principal Structure Application July 2014
Town of Queensbury tea L(� Thomas R. Van Ness
Highway Department 1 - 5—\ Highway Superintendent
742 Bay Road, Queensbury, NY 12804 Home: (518) 745-0929
Phone: (518) 761-8211 ]+Lo� /
Fax: (518)745-4466 David Duel[
Deputy Highway Superintendent
Home: (518) 745-0938
DRIVEWAY PERMIT
Date: 1Z l`l 14'
Applicant Name: !2!G[a�✓L19 ��
Telephone No.:
Address to Be Inspected: Lel GRA / ��H
Return Address: 6� Gift-;5- V-Opt�
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
7
Town of Queensbury Building&Codes Principal Structure Application July 2014
SEPTiv DiSPOSrAI PERNA11T
/ Office Use Only
DATE Lf�� ��¢ Received
Tax Map ID
TAXMAPID �IOR• 1'� ' Z' �l . Z Permit No.
/1 7,� /' IA- Permit Fee
LOCATION OF/NSTALLATION m (A-�("G✓T U"Okeg Approvals:
APPLICANT 11 I�/ I 6 ! ,r��/ '/!,�
kl"M W t • V Ori L/'L ffQ LUG. PHONE/E-MAIL /'L z2 – )01
� U �iJS12t)1ADDRESS 1-
b64-INSTALLER/BUILDER: PHONE/E-MAIL
ADDRESS:
OWNER W�0rJ 0940'LA2A 1Z PHONE/E-MAIL
Address II Afl`l' I20LFY! l U�rJS✓�Ul�� �`{ � 1&r5a#-
r�� 1
CONTACT PERSON FOR BUILDING&CODES COMPLIANCE: i"L CA�� V d(J g� PHONE
RESIDENCE INFORMATION
Year Built #of bedrooms X Gallons per bedroom =Total Daily Flow
1980 or older Garbage grinder installed Y —N
1981-1991 Spa or Hot Tub installed Y _N
1992-Present
PARCEL INFORMATION
Topography Flat rolling _Steep slope _%slope
Soil Nature Sand _Loam _Clay _Other
Groundwater At what depth? 140 -t i
Bedrock/Impervious Material At what depth? ZD :t
Domestic Water Supply Municipal _Well (if well,water supply from any septic system absorption is_ft.)
Percolation Test Rate: Li5jd1✓j_per minute per inch(test to be completed by licensed engineering/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION
Tank Size 3yx0 gallons(minimum size 1,000 gallons, add 250 gallons to size for each garbage grinder or spa or hot tub)
System Type Absorption field with#2 stone Total length ft.; Each trench 1 ) x 6r L
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&approved. The installed system must match the septic system
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 know by or on behalf of an applicant, shall be void. I have read the regulations
and agree to abide b,y�(these,and all re uiremeqis of the Town of QueensburySanitary Sewage Dis opal Ordinance,
Print Name: (` GL�+6t U-0 q • Vont Date: -Ll
Signature: .r/ Date:
6
Town of Queensbury Building&Codes Principal Structure Application July 2014