applications — tiOJ d-1 -
Office Use Only
Permit#: RCol502�01 /
4,t PRINCIPLE STRUCTURE PERMIT
APPLICATION Permit Fee:$
Town of Queensb ur $
742 Bay Road,Queensbury,NY 12804 *Rec Fee: i7
P:518-761-8256 www.queensbury.net Invoice#: 14 (7 Ckdo
Project Location: //?(r {' C.hmnnd i i t Dr.
Tax Map ID#: 30$. 7 - ( 7g Subdivision Name: Txtrrin3er keign#S
*TOWN BD.RESOLUTION 86-2013: $850 recreation fee for new dwelling units: single ffmil-yTduale: twwe farrft f,
multiple family, apartments, condominiums,townhouses, and/or manufactured &modul r Ux riot rr pbiWW` #'
homes. This Is In addition to the permit fee(s). ILA �® jl
CONTACT INFORMATION: APR 2 6 201
u
• Applicant: ,
f Ai' 4, t S VE Nij
�
Name(s): Iocic ou)5k.. 1-1omes W
Mailing Address, C/S/Z: 1q(Q ZikIr c1ecc d- achenec • • , /a3060
Cell Phone: ( ) Land Line: (55/ , ) 35(, - 1`t 35
Email: ()CLu �. \1nx,ocnuac k t joup. P.n m
• Primary Owner(s):
Name(s): Bur
Mailing Address, C/S/Z: "KO, "at xdecc SE <`�C_'1esieLAMv3, (y 1abCL
Cell Phone: ( ) Land Line: (,Sill ) 35(, - 1435
Email: �� K locks-or.ag t Jro .corn
• Contractor(s):
Business Name: 14,c1pcoL Ski l t rne.5
Contact Name(s): Cocc0.cl.%
Mailing Address, C/S/Z: 7q(, F t,4.rdec,r 5 Sc eneG-#o y :M'J I a3CC'
Cell Phone: (6 (g ) 3(05 - $$t)-1 Land Line: (5 tk ) 35 to - 1135
Email: pepe,& hodocouDskr oc• Cnm
• Architect(s)/Engineer(s): e�
Business Name: 1\104, cos dome Desi ns LLL
Contact Name(s): 35 Nrler-rt (.,asic_ 'Ct,n1
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: (5(' ) 30(e — sqS/
Email: Iq(og nyo.p. rr. Cxr
Contact Person for Building & Code Compliance: Pep elyrradc
Cell Phone: (5 ik ) 3(05- &SD/ Land Line: .( )
Email: ` C `nodD -oi... .,r yccup. corn
Town of Queensbury Building&Code Enforcement Principle Structure Application Revised February 2017
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PROJECT INFORMATION:
TYPE: Commercial Residential
WORK CLASS:
v7 Single-Family Two-Family Multi-Family(#of units
Townhouse —Business Office Retail _Hotel/Motel
Industrial/Warehouse Garage (#of cars ) ^Other (describe
SQUARE FOOTAGE:
I st floor: /a(1,4 +/_
2nd floor: q 90. 54t, t
3rd floor:
4th floor:
Total square feet: a a 5 4.""
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ e D DOD
2. Proposed use of the building:
3. If Commercial or Industrial, indicate the name of the business:
4. Source of Heat (circle one): Oil Propane Solar Other
Fireplaces need a separate Fue Burning Appliances&Chimney Application, one per appliance
S. Are there any structures not shown on the plot plan? YES Explain:
6. Are there any easements on the property? YES NO
7. SITE INFORMATION:a. What is the dimensions or acreage of the parcel? • 4 g +/—
b. Is this a corner lot? YES NO
c. Will the grade be changed as a result of the construction? YES NO
d. What is the water source? PUBLIC PRIVATE WELL
e. Is the parcel on SEWER or a ERTVATE SEPTIC syster ?
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 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: bCkOcp
SIGNATURE: DATE: 14
Town of Queensbury Building&Code Enforcement Principle Structure Application Revised February 2017
réac %-n;1 le (' (-1,Zelt
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FUEL BURNING APPLIANCE & Office Use Only L�
CHIMNEY APPLICATION Permit#: C `1 S—`-D-6`/
Permit Fee:$ P o-
ro4177 of Ouccnsbur
742 Bay Road, Queensbury, NY 12804 Invoice:#:
P:518-761-8256 www.queensbury.net
Project Location: lac, Richmond I-WI? Dr. Tax Map ID #: 308. 1 .-1 -78
Room of Install: Planned Install Date:
**ONE APPLICATION PER APPLIANCE** Li r_____,
PR 2 6 20 19 I j
CONTACT INFORMATION: TOWN P O i " °= 13 URY
COMM4ON: :.,,:�L�`�,PM.CN-f
• Applicant:
Name(s): NockorowSk,'t Nonne-3
Mailing Address, C/S/Z: -796, 1'u 8ezx , _, ranpnr u , 1\I'I td30(a
Cell Phone: ( # ) Land Line: ( 5/ )j 3,5G - Psi 35
Email: \-\0aocovos 0u�. Co fl
• Primary Owner(s): J
Name(s): ON 55ipi1 'R'jw:\ eerS
Mailing Address, C/S/Z: '1q 6 ` c8,ec st 31nef1P �, ti lJ )a 30(o
Cell Phone:_( ) Land Line: _( __) 3540 -/y-35
Email: P°'_a & V\oaorouDak..3t-oue. r_prrl
• Installer/Builder: .
Business Name: V\(3 ab 'oLosk_A \kooncs
Contact Name(s): iPec Cbcc A%
Mailing Address, C/S/Z: 19(0 c \I la3o
Cell Phone:_(5(8 ) 3(05 -g gb7 Land Line: _(518' 154, - 14435
Email: c e e. 4c \1cAorou k5CoLip. 0 nm
Contact Person for Building & Code Compliance: ()eQ C. roac,
Cell Phone: _( �-) - D Land Line: ( )
Email: C,aJ Nno rou3SkiyO .!'inn
Fuel Burning Appliance &Chimney Application Revised March 2017
4,
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%.,„,p«`,dr Model#: -- 1 �O3<5
SOURCE OF HEAT: ``
Wood Coal Pellet /Gas
CHIMNEY INFORMATION: iIi Qcts dt.reck veil+.
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:"Pa. 1'[O80r°u.DS
SIGNATURE: k._/-N-------
p DATE: Li/ao2 jcl
Fuel Burning Appliance &Chimney Application Revised March 2017
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SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
Bay y Road,Queensbury,NY 12804
-town 50�
>,,„rcZ r,Khnuf Permit#: lJ P:518-761-8256 www.queensburv.net
Tax Map ID#: (I- 7g Permit Fee:$ ; Invoice#:
ale Project Location: e �c.rlmbn C� �i I( Dr. Septic Variance? Yes No
Primary Owner(s) Mi9si0n '?)tiAc e-r-S
Mailing Address 7q� 'jwc-�Qe�L Schener -Ci • N`l la3o(a
Phone& Email 51S/ • • I435 \no Anir()tOs\O.c oU f• Cprf
Installer/Builder VA odor 0 OSk,.t Nn(fC5
Mailing Address lq(p /etu-ra-eLK 3,.le) Ny /Q50(0
Phone & Email 518 • 25(0. 1435 co @ )60cg 514-% \rOL‘e•CDrn
EngineerNi
®�9 Of\ 1-) Q-r) #ev La v J bS
Mailing Address (12q + 0.uA,Ourl tl 1�Cj u-e•er15\0 * ila g
Phone &Email 511 • 1' a • 5(414
Contact Person for Building&Code Compliance:Pc s �t:6rnt Phone: 51$ - 3(0,5 -00o7
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.PRINT NAME: "P(3 \ 'VA v CS,Qy-00.3SK.A DATE: 11' aa-�,
SIGNATURE: DATE: \90- 6
Town of Queensbury Building&Code Enforcement Revised February 2017