applications Office Use Only
6.
Permit#: f g C—D 6— %
PRINCIPLE STRUCTURE PERMIT
,`` APPLICATION Permit Fee:$ 7! /t 0
•Town ofQueensbury *Rec Fee: $ 00
742 Bay Road,Queensbury,NY 12804
P: 518-761-8256 www.queensbury.net Invoice#:
Project Location: I I \.•1c t =1`l �_D►mil
Tax Map ID #: '3O . ( Z — (~ 2� Subdivision Name: R T
*TOWN BD. RESOLUTION 86-2013: $850 recreation fee for".1 ,na ccr l fi Unit*: t afnily,duplexes/two-family,
multiple family, apartments, condominiums, townhouses, ri o-rentifeetu ed mid I r'homes, but not mobile
homes. This Is In addition to the permit fee(s). rJ
JUN 10 2019
CONTACT INFORMATION: 3
TOWN OF OUEENSBURY
BUILDING&CODES
• Applicant:
Name(s): 1 C.1-41 S Q1 L kC*J c L1-.C-
Mailing Address, C/S/Z:_ I MDAz-TAsS WA�Y r-�I 4p1\ltC�l1�-►—'� 1M1Y 1 Z-14e,
Cell Phone: ( 51`a ) (a9q • 142.31 I Land Line: ( 5t`2) ) (..,-St I
Email: '-E -e
• Primary Owner(s):
Name(s): gam -
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: (
Email:
• Contractor(s):
Business Name: SP '- As, a47,0.1- ,
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: (
Email:
• Architect(s)/Engineer(s):
Business Name: KE1 lz-3•-Y1Eu , F .•
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: ( ) -1q• 2402_ Land Line: (
Email: \ rt re!:fw% eAIYC_A . 17—R..ck
Contact Person for Building & Code Compliance: T01y' 1-spc.1.scxo
Cell Phone: ( S'`b ) `551•3j4-4 Land Line: (
Email: 'C e M Cc -
Town of Queensbury Building&Code Enforcement Principle Structure Application Revised February 2017
PROJECT INFORMATION:
TYPE: Commercial X id
WORK CLASS:
X Single-Family Two-Family l\Aulti-Family(#of )
Townhouse Business Office Retail Hotel/Motel
Industrial/Warehouse Garage(#of cars ) Other(describe )
STRUCTURE SQUARE FOOTAGE: GARAGE SQUARE FOOTAGE:
1ST floor: t O�� C�7 1ST floor: '4 c'l
2nd floor: 91-2 4 clp 2nd floor:
3rd floor: Total square feet: 4 9
4th floor:
Total square feet: t ,ct t ,5 4
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ Z 6 d"
2. Proposed use of the building: s111c{L r-Pk`V%-`+1 15>I1s C,a-
3. If Commercial or Industrial, indicate the name of the business:
4. Source of Heat (circle one): 40 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 NO Explain:
6. Are there any easements on the property? YES NO
7. SITE INFORMATION:
a. What is the dimensions or acreage of ,e parcel? /.s
b. Is this a corner lot? YES
c. Will the grade be changed as a resu t of the construction? YES NO
d. What is the water source? ICUBLICD PRIVATE WELL
e. Is the parcel on SEWER or a PRIVATE SEPTIC system?
Town of Queensbury Building&Code Enforcement Principle Structure Appication Revised February 2017
DECLARATION:
I. 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: �� •� 17. 1.46c Gd
SIGNATURE: � DATE: 4 /o / c
l
•
Town of Queensbury Building&Code Enforcement Principle Structure Application Revised February 2017
Town of Queensbury Thomas R. Van Ness
Highway Superintendent
Highway Home (518) 745-0929
Department
742 Bay Road—Queensbury, NY 12801 David Duell
Phone: (518) 761-8211 Deputy Highway Superintendent
Fax: (518) 745-4466 Home (518) 743-0938
DRIVEWAY PERMIT
DATE: b14119
APPLICANT NAME: MICA-Wet-5 c( P) c ,
TELEPHONE NO.: .l0311
ADDRESS TO BE INSPECTED: I 1 Woa 'E lam=
RETURN ADDRESS: 1 I•AD voNS WA—f
1v1a-t0.Nk0.1%u.�L hlY iZ1Ve.
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:
Thomas R. Van Ness, Highway Superintendent David Duell, Deputy Highway Superintendent
•
FUEL BURNING APPLIANCE & Office Use Only
• CHIMNEY APPLICATION Permit#: ' bb o - 2�1`)
Permit Fee:$
finvn of(Zircensbur;v
Invoice:#:
742 Bay Road,Queensbury, NY 12804
P: 518-761-8256 www.queensbury.net
Project Location: l 1 Tax Map ID #:
Room of Install: c E7 Zr CArd Planned Install Date:
**ONE APPLICATION PER APPLIANCE**
CONTACT INFORMATION:
• Applicant:
Na me(s): tC -tb s , �-�-c-
Mailing Address, C/S/Z: 1 NIAc'S Wb.Y, 1#{aa-1Pqtr_x[it1-ei NY Yule
Cell Phone: ( ) Ef+G.(o'7..►ti Land Line: (
Email: J talc.,-tbeo-s.qrzos—�•ctso�l
• Primary Owner(s):
Name(s): - / =
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line: _( )
Email:
• Installer/Builder:
Business Name: TT 1-t c * Pp-"C\0
Contact Name(s): c.itzect }-{,M),LounnA
Mailing Address, C/S/Z: 1-7bo , 12'zc
Cell Phone: _( 5R> ) '8oci" Land Line: _( )
Email:
Contact Person for Building & Code Compliance: 17.34-C wcA.sC-tit
Cell Phone: ( 561) ) I44- Land Line: (
Email: 'T wC-.scat 1J►‘4taQ. (O.
Fuel Burning Appliance &Chimney Application Revised March 2017
FUEL BURNING APPLIANCE INFORMATION:
TYPE OF DEVICE:
Stove Fireplace Insert V.Fireplace
Fuel Fired Equipment (Garage Only, 18" clearance per IMC 304.3)
X Fireplace, factory built**
**Manufacturer's name: He - N- C.ltc Model #: (01-301�>
SOURCE OF HEAT:
Wood Coal Pellet )4 Gas
CHIMNEY INFORMATION:
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:a
PRINT NAME: P l��� �, c64b
SIGNATURE: �� DATE: Cl/c (`l
Fuel Burning Appliance & himney Application Revised March 2017
is
SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
742 Bay Road,Queensbury,NY 12804
(" rc Permit#: V-C• ^ 0�J'b • 2-0 I.P:518-761-8256 www.queensburv.net
Tax Map ID#: Permit Fee: $ ; Invoice#:
Project Location: 11 3T.- Septic Variance? Yes No
Primary Owner(s) M‘UfDd..s 4eioP
Mailing Address i p c,4ys trite Mtr_4-kA N1C•l1us3", ts� IZ�tO
Phone & Email ‘a) e I c-e-aN,FASCt �. cc�M
Installer/Builder Nc-.
Mailing Address ►AcD1111-‘ L-Ls N.Y 2._4?) 9
Phone & Email \ , '131 I
Engineer E1.>,C�1t-4.- 1V4{ P.C..
Mailing Address lccfc tzA> cam, av ,.P ►•i ' I2'c p 4
Phone & Email 51'3
Contact Person for Building&Code Compliance: 1 -1 C Phone: 5V8 •a": 1
RESIDENCE INFORMATION:
Year Built #of bedrooms X gallons per bedroom =total daily flow Garbage Grinder Yes (Now
1980 or older Installed? (circle one)
1981 1991 Spa or Hot Tub Yes N oi)Installed? (circle one)
1992-Present J / ( r 3 3
PARCEL INFORMATION:
Topography Flat Rolling Steep Slope %Slope
Soil Nature k Sand Loam Clay Other
Groundwater At what depth? k1,1
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(- / /
PRINT NAME: '^T �"`� / ` `9 S CCU DATE: / /�
t 7 /r
SIGNATURE: DATE:
Town of Queensbury Building Code Enforcement Revised February 2017