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applicationsPRINCIPLE STRUCTURE Office Use Only PERMIT APPLICATION Town of Queensbury 742 Bay Road,Queensbury,NY 12804 P:518-7648256 www.queensburynet i “L ||FEB 11 2020 Project Location:Kimberly bad!: Tax Map #:_208 16-2-58,Subdivision Name: _ TOWN BD.RESOLUTION 86-2013:$850 recreation fee for new dwelling units:single family,duplexes/two-family, multiplefamily,apartments,condominiums,townhouses,and/or manufactured &modular homes,but not mobile homes.This is in addition to the permit fee(s). CONTACT INFORMATION: ¢Applicant: Name(s):Monsouy Fatag rises LLC Mailing Address,C/S/Z:__/|eorve Bel by NY /2eDY¥ Cell Phone:_(516 )__Yb/-)7).Land Line:_() Email:__Doue (¢GOcTE tom +Primary Owner(s): Name(s):ame5Agicced Mailing Address,C/S/Z:‘ Cell Phone:_()Land Line:_() Email: O Check if all work will be performed by homeowner only ©Contractor(s):Workers’Comp documentation must be submitted with this application Contractor Name(s):foun Atyuchal C2 20 Contractor Trade: Mailing Address,C/S/2: Cell Phone:_()land Line:_() Email: **List all additional contractors on the back of this form +Architect(s)/Engineer(s): Business Name: Contact Name(s): Mailing Address,C/S/Z: Cell Phone:_()Land Line:_() Email: Contact Person for Building &Code Compliance:Von 50 Cell Phone:_(Sif )__Yb/-12>land Line:_() Email:__Due t GOCLF.Corr Princole Structure Packet Reviced February 2010 PROJECT INFORMATION: TYPE:__Commercial _X Residential WORK CLASS: >Single-Family __Two-Family __Multi-Family (#of units __) __Townhouse __Business Office __Retail __Hotel/Motel __Industria/Warehouse __Garage(#ofcars__)_Other(describe ) STRUCTURE SQUARE FOOTAGE:GARAGE SQUARE FOOTAGE: I floor:__{051 a"floor:__a2"floor:__98>2 floor: 3 floor:SEER!Total square feet:__Lay Basement (habitable space): Total square feet:AO3Y = ADDITIONAL PROJECT INFORMATION: 1,Estimated Cost of Construction:$_360,00 2.Proposed use of the building:Hoque 3.If Commercial or Industrial,indicate the name of the busine: 4.Source of Heat (Gay 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 @O)Explain: 6.Are there any easements on the property?YES AO» 7.SITE INFORMATION: a.What is the dimensions or acreage of the parcel?LYAX 29b.Is this a corner lot?YES (Wi c.Will the grade be changed as a resultof the construction?YES.(WO) d.What is the water source?UBI PRIVATE WELL e.Is the parcel on SEWER or a PRIVATE SEPTIC system?___Aaoh'c Princiole Structure Packet Revised February 2019 DECLARATION: |.lacknowledge that no construction shall commence priorto issuance of a valid building permit and work will be completed within a 12 month period 2.Ifthe work is not completed by the tyear expiration date the permit may be renewed, subject to fees and department approval. 3.|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,|acknowledge that prior to occupying the facilities proposed I,or my agents,will obtain a certificate of occupancy. 5.|understand that live are required to provide an as-built survey bya licensed land surveyor of ail newly constructed facilities prior to issuance ofa certificate of occupancy. |have read and agree to the above: PRINT NAME:Droid Mearous SIGNATURE:Ue DATE:__a>lag Princinle Structure Packet Revised February 2010 Office Use Only FUEL BURNING APPLIANCE &Permit =feeOmw CAZORe CHIMNEY APPLICATION Permit Fee:$. Invoice #: 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 wows Project Location:_I{Eimbirly Ln.Tax Map ID:__309.j)8-2-59.3 Room of Install:_Liviias eon Planned Install Date:___Ma5 anaes **ONE APPLICATION PER APPLIANCE* CONTACT INFORMATION: ©Applicant: Name(s):__Meispuk Entipsises 1OC Mailing Address,C/S/Z:__4/)eure Rel Aby AY 160¥ Cell Ph:__(4i%)Yb)-191%Land Line:__(), Email:vue ce GO¢7T F.Coen ©Primary Owner(s): Name(s):Sawe OS Apiicant Mailing Address,C/S/Z: Cell Ph.:_()Land Line:__() Email: O Check if all work will be performed by homeowner only ¢Installer/Builder:Workers’Comp documentation must be submitted with this application Contact Name(s):CEQ)Bee Contractor Trade: Mailing Address,C/S/Z: Cell Phone:_(___).Land Line:_() Email: Contact Person for Building &Code Compliance:De Nomour Cell Ph:__(51@_)_YA/-)))Land Line:__(__).Email.fYwe G 6022 F.Coc Principle Structure Packet Revised February 2019, FUEL BURNING APPLIANCE INFORMATION: ‘TYPE OF DEVICE: __Stove >Fireplace Insert __Fireplace ___Fuel Fired Equipment (Garage Only,18”clearance per IMC 304.3) x Fireplace,factory built** (**Manufacturer’s name:Heat +Glo Model #:___L000 CL ) &Sarctonn Flrplce +Stove wok Titel +VertSOURCEOFHEAT: ___Wood __Coal ___Pellet X Gas CHIMNEY INFORMATION:Ay vended over Goble Wali dy ___Masonry (require plans to be submitted): ___block __brick __stone __Flue: __tile __steel —___size,in inches _Material*: __double-wall ___triple-wall __insulated (*Manufacturer’s name:Model #:) ADDITIONAL INFORMATIO! 1.Two inspections are required.A rough-in inspection,prior to installation and a final inspection,after installation. Manufacturer's installation manual must be available at the time of inspection. Masonry fireplaces &chimneys require plans to be submitted. Twenty-four (24)hour notification is required for inspections. Workers’Comp insurance information is required with this application. Ae 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. |have read and agree to the above: PRINT NAME:Dewitt Monsous SIGNATURE:dl =pate:_2/>b, Principle Structure Packet Revised February 2019, Office Use Only Twnofasoter SEPTIC DISPOSAL PERMIT APPLICATION —_| P&™ Permit Fee:$;Invoice Septic Variance?Yes 2025 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.queensbury.net Tax Map ID#:__208J6-2-4A,.%0ProjectLocation: _J|_KimblyJ©Applicant: Name(s):Moarour Entenryises Ler Mailing Address,C/S/Z:ti)Reverse cl Ob,AY laeoy Cell Phone:(Sif)YAl-17)Land Line:_() Email:Doe O02 LE Cor ¢Primary Owner(s): Name(s):we cn Apa licedt Mailing Address,C/S/Z: Cell Phone:-()Land Line:_() Email: O Check if all work will be performed by homeowner only ¢Contractor:Workers’Comp documentation must be submitted with this application Contact Name(s):CWarlos Exicclven Ereauct Contractor Trade:Li Cavrato# Mailing Address,C/S/Z:Y Moin St Hucinn Fells WY Cell Phone:_()land Line:_(_sip )__24¥7-937) Email: ¢Engineer(s): Name(s): Mailing Address,C/S/Z: Cell Phone:_()Land Line:_() Email: Contact Person for Building &Code Compliance:___Daud (pasowrCellPhone:(54)Yb/-/713 Land Line:_() Email:Duwt_&GOCTE Cop? Principle Structure Packet Revised February 2019, RESIDENCE INFORMATION Year Built Gallons|#of bedrooms:|X gallons per|=total daily flow per day bedroom Garbage Grinder Yes|(%,| 1980 orolder|150 lt Installed?(circle one) 4 7981-1991 730 ‘Spa or Hot Tub Yes |(No,|Installed?(circle one)1992-Present|110 Y no 4D PARCEL INFORMATION: ‘Topography {Flat Rolling ‘Steep Slope %Slope Soil Nature XL Sand loam —__Clay_—_—_Other (explain: Groundwater Atwhatdepth?Vlowe Found -Bedrock/Impervious material|Atwhatdepth?ous fend =Domestic Water Supply _A.Municipal___Well (if well,water supply from any septic system absorption is___ft.) Rate:per minute per inch (test to be completed by licensed engineer/architect) PROPOSED SYSTEM FOR NEW CONSTRUCTION: Tank size|J260 gallons (min.size 1,000 gallons,add 250 gallons for each garbage cylinder or spa/hot tub System ‘Absorption field with #2 stone|Totallength 3G ft;EachTrench_ft. Seepage Pit with #3 stone How many:;Size: = Alternative System Z Bed or other type: Holding Tank System Total required capacity?;tank size;#of tanks: .Alarm system and 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.3.As-built drawings must be submitted prior to the inspection,if there has been a change to the submitted plans. 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.|have read the regulations and agree to abide by these and all requirements of the Town of Queensbury Sanitary Sewage Disposal Ordinance. PRINT NAME:David Moarour pate:__2/>he i SIGNATURE:MA =pare:sac Principle Structure Packet Revised February 2019,