applications f Office Use Only
PRINCIPLE STRUCTURE PERMIT
Permit#: - 02b5
w_ APPLICATION Permit Fee:$ 1 O 58- )0
3 a .,
742 Bay Road,Queensbury, NV 12804 *Rec. Fee:$ tc,0
P: 518-761-8256 _ Invoice#: 1418 2_.
Project Location: 115 lei icon nonc� Will Dr.
Tax Map #: 30 g . 7— ' (a`+ Subdivision Name:?o rri nyx n eig b-1
TOWN BD.RESOLUTION 86-2013:$850 recreation fee for new dwelling units: single family,duplexes/two-family,
multiplefamily, apartments.condominiums townhouses,and/or manufactured & modular homes, but not mobile
homes. This is in addition to the permit fee(s). « ,
CONTACT INFORMATION:
• Applicant:
Name(s): Homet, TOWN OF Qa a 3 R Y
COMMailing Address, C/S/Z: 7q(, l�urclecic M- 5chenec o N'i ry s�i 3iB a �' .aF -rb ; z,T
Cell Ph.: _( ) Land Line: _(51$ ) 35(p - N35
Email: p.A.,Q Q hnA o ups k.01.0 u1s.Ccarn
• Primary Owner(s):
Name(s): Mi53;
Mailing Address, C/S/Z: -7q(% 5drifine • . 1 Nv I a3Oc.0
Cell Ph.: _( ) Land Line: (51: ) 351& - 143,5"
Email: ?clikOrme\orok..0.*:%you_9. Corn
• Contractor(s):
Name(s): kock>cc sk+ 1-bme�
Mailing Address, C/S/Z: iql, j_k 3c;nenet± _ (\N /CMG,
Cell Ph.: ( ) Land Line: _(5f ) 35 , /1-35
Email: f)n.ui \noclryrotoska'rov.Q. etm
• Architect(s)/Enqineer(s):
Name(s): Ntor4-1n ur \-korne D esi o �
Mailing Address, C/S/Z: 35 Glnercu�Trpe_ Lane, VI itton Ny Cell Ph.: _( ) Land Line: _(,`j -1R ) 3O(o5' 5f
Email: jkcLztclle$ C �nc�P. rr. cam
Contact Person for Building & Code Compliance: ..4) CY('cc&dt
Cell Ph.: (5(E ) 365- $S67 Land Line: ( )
Email: pe_&__. Vnextx-oc.J.sK.i rnu,�. c.orr)
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:
1ST floor: I a(o Li- 41— 1ST floor:
2nd floor: I at Co 3 11— 2nd floor:
3'floor:
Total square feet: 5`tw ; '
Basement(habitable space):
Total square feet: o�5 a-t iv
--
ADDITIONAL PROJECT INFORMATION:
I. Estimated Cost of Construction: $ o?C;b ( cO
2. Proposed use of the building: Ss,hc3 P - li cal t I i ns
3, If Commercial or Industrial, indicate the name of the business:
4. Source of Heat(circle one): 4310 Oil Propane Solar Other:
(Fireplaces need a separate Fue Burning Appliances&Chimney Application,one per appliance)
5. Are there any structures not shown on the plot plan? YES °Explain:
6. Are there any easements on the property? YES V
7. SITE INFORMATION:
a. What is the dimensions or acreage of a e parcel? • 5 7 ÷/-
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? ,PUBLI PRIVATE WELL
e. Is the parcel on SEWER or PRIVATE SEPTIC)ystem?
'DECLARATION:
I. lacknowledge 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 approve I.
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 i, or my agents, will obtain a
certificate of occupancy.
5. I understand that Me 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: 'i'lui.\ 1-AnANrD
SIGNATURE: DATE: `f 1 24 119
'` << Office Use Only
yif
FUEL BURNING APPLIANCE & Permit#: ' -t42,5 - 2-QA
CHIMNEY APPLICATION Permit Fee:$
v Invoice#:
if 01 eellsbu
742 Bay Road, Queensbury. NY 12804 P:
518-761-8256 www.�u ..:r;:.s_: ,3 net
Project Location: 115 'PiiChrnc 6 u;I1 A:Tax Map ID: 308, 7 - 1 - 101f
Room of Install: em°
rP-Q� 1�i0o�Yl Planned install Date: i i''?=°
?AY' 0 t 2`'�
**ONE APPLICATION PERAPPLIANCE** `'
OOMMLIl"E°i OPMET
CONTACT INFORMATION: a _� ,
• Applicant:
Name(s): N o c40c \-\0 ores
Mailing Address, C/S/Z: 7 qte 'E L rclecj< S-I Schen erfra , NV 12 3o(0
Cell Ph.: _( ) Land Line:_(5 I$ 3567- 14 35
Email: QoJ. \ @ Inoclorok..on \o jou . Ctm
• Primary Owner(s):
Name(s): M\SSion 1' ut lc`ec s
Mailing Address, C/S/Z: -Taco "Uurcle.ck S� ���nec-dad N 1 /a3C6
Cell Ph.: ( ) Land Line: ( 5/k ) 35(P - Pf 35
Email: -.. --- &_ hod ou)5k ofo . Com
• Installer/Builder:
Name(s): N6 domes
Mailing Address, C/S/Z: 79(0 'burcierk Ss heier-l-ark Ny /(230(
Cell Ph.: _( ) Land Line: (5/g ) 356 - 14135
Email: ‘- n Q \n o cbc o• ):‘ r . Cpm
Contact Person for Building & Code Compliance: Vep C.OKral
Cell Ph.: ( 518 ) 3( 5 - 380'7 Land Line: ( )
Email: Qei)cQ \nocinroups sfoup. corn
Town of Oueensbury Building&Code Enforcement
b
S d ,
FUEL BURNING APPLIANCE INFORMATION:
TYPE OF DEVICE:
Stove Fireplace Insert /Fireplace
Fuel Fired Equipment(Garage Only,B"clearance per IMC 304.3)
Fireplace, factory built**
** Manufacturer's Name: `)tj p.er 1C)(' Model#: DRV
SOURCE OF HEAT:
Wood Coal Pellet 4E0
CHIMNEY INFORMATION: f\iIn Cc0a5 cic-ed-d \fo 4
_Masonry:
block brick stone
Flue:
tie steel size,in inches
Material*:
double-wall _ triple-wa II_insulated
("Manufacturer's r-i m = 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 ofthese 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: P z iAp p, —
SIGNATURE : DIN": Ll a I9
Fuel Burning Appliance&Chimney Application
, E.r' f 1.
'_ j SEPTIC DISPOSAL PERMIT AI? IC_4l`IN J. -. c �uanl
742 Bay Road,Queensbury,NY 1280,-
�P.518-761-8256 ,i,," Prmt#` i -C -Q2 (Qra • ZQI.1,
I L
Tax Map ID#: 30F. 7 (o i e:. -Invoice#:
Project Location: Gi1w1i Il..v._Y erptfari ? Yes -
No
Primary Owner(s) /`'f 1.55/Col'1 6Ui Icter5
Mailing Address -1q4 ' usd-ec1L S•t 3cY)enec)c , WI /'3nte
Phone & Email
518 • 35(o• Iy35 Qc Q & hocAorou-DSKacl�6�•Com
Installer/Builder �o&)rovos_k.-, OOmes
Mailing Address 1 ct(o tkcAe6C 5- 5oneneC Ni`I /a30i4,
Phone & Email 51 g • 354.• 1143 {p d a iNc0A.Oc k;,yoLq. Corn
Engineer \ l�USex, 4 akeV e,s
Mailing Address I VA !-\am'kan d T13, n ,.eens\Uu r- , N`I /918 o'+
Phone& Email 51$ • icy a_ sy1'4
Contact Person for Building&Code C,t•.:•m pal fiance:P-f&.fC,kd4 F'Iriean : 5tg• 3(a5• 88'67
RESIDENCE NFORMATION:
_
Year Built 1 #of bedrooms X gallons per bedroom = totaldaily flow Garbage Grinder Yes No
1980 or older Installed? {circle one)
1981-1991 0
Spa or Hot Tub Yes No
P Installed? {circle one)
. 92-Present _ ____—
PARCEL NFORMATION:
Topography Flat Rolling Steep Slope %Slope
Soil Nature Sand !Loam Clay __Other
Groundwater At what depth?
Bedrock/Imperviousmaterial At what depth?
Domestic Water Supply _Municipal _Well{if well,wate r supply from any septic system absorption is ft.)
Percolation Test Rate: per minute per inch{test to be completed by licensed engneer/archtect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size 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 ft.;EachTrench ft.
Seepage Pit with#3 stone How many: -Size:
Alternative System I Bed or other type:
HoldingTank System Total required capacity? •tank size ;# of tanks
NOTES:1.Alarm system&associated electrica Iwo rk must be inspected bya Town approved electrical inspection
agency;2.We wi II 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 orfailure to make a material fact or circumstance known by or on behalf of an applicant, shall be void.1
have read the regulations and agree to abide by these and all requirements oftheTown of Queensbury Sanitary Sewage
Disposal Ordinance.
PRINT NAME: �i t - iA II ..6. 6 _ _, • DATE: y't�`�\1.9
c ..----- -----2
SIGNATURE: DATE: 1�Li\2it-k
Rot.>o.-1 Frahm vane 9n.n