applications PRINCIPAL STRUCTURE APPLI ATION Office Use Only
DATEReceived
mm Tax Map ICS � I`
a7 Permit No. P'(4-
Permit
(4
Tom"ti7rt�)D � �� �
�� � �� � t� Hec Fee .,��_.� � ��`�
Permit Fee
ZONING
� '"L
HISTORIC,SITE des _ N Sub d')6io
SUBDIVISIONANAME Lot�# � .
Tom B INC" l l AMID c ELLINGs,CDt7PLI XES
OR TWO FAMILY DWELLINGS, MULTIPLE ;
.RESULLITIC►NB -23: iSQ1=cnTlacu Fc�r Iv �rrrawL
FAMILY DWELLINGS, APARTMENTS, � , ANC!/(�Ft MANUFACTURED �
MODULAR HOMES, BUT NOT MOBILE HOMES. THIS IS IN ADDITION TO THE PERMIT FEE.
APPLICANT ' OWNER
ADDRESS �
"` �, ADDRESS .
PHONE/E-MAIL ?Z—K ' . - PHONE/E-MAIL
CONTRACTOR COST OF CONSTRUCTION(ES77MATED). $ ,7
ADDRESS: BUILDING ADDRESS:
PHONE/E-MAIL
CONTACT PERSON FOR BUILDING&CODES COMPLIANCE: PHONE
TYPE OF CONSTRUCTION
Check all that apply Please indicate measurements as required below
New Addition Alteration 1s'floor sq.ft. "d floor sq.ft. Total sq.ft. Height
Single Family
Two-Family
Multi-Family
(# of units )
Townhouse
Business Office
Retail- Mercantile
Factory- Industrial
Attached Garage
ot
Other
1
Town of Queensbury Building&Codes Principal Structure Application July 2014
SEPTIC DISPOSAL PERMIT Office Use Only
DATE `w
TAX NAP ltd IIerm`�t �
B� h er e
p„i
Zulu
LOCATION oFINSTALLATION � rauals
ag
%
.APPLICANT ''� - u PHoNE✓'E-EvtAlt � ✓''
ADDRESS
11VSTALLER/l3`uxDEn PHONE/E-MAIL J >
ADDRESS W
0WtVER I / PRONE/E-MAIC
Address
CONTACT PERSON FOR BUILDING&CODES COMPLIANCE: I& z, PNC)11dE
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
Topographylat rolling Steep slope %slope
Soil.Nature X Sand Loam Clay Other
Groundwater At what depth?
Bedrock/Impervious Material At whgt 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 licensers engineering/architect)
PROPOSED SysTEM FOR NEW CONSTRUCTION
Tank Size ZA2LL 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 x
Seepage Pit with#3 stone Haw many: ;size
Alternative System Bed or other type?
Holding Tank System Total required capacity? Tank size #of tanks
Motes: 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.
QgcLARATION: 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 by these an all re . ements of the Town of Queensbury Sanitary Sewage DiSpo at rdinance.
Print Name: /Z.e M Date: 6
Signature: Cate: rel
6
Town of Queensbury Building&Codes Principal Structure Application July 2014
If commercial or industrial indicate name of business
Proposed use of building or addition
Source of heat(circle one) as Oil Propane Solar Other
Fireplace: complete a separate application for Fuel Burning Appliances&
Chimneys X/A
Are there structures not shown on plot plan? it/A
Are there easements on the property? ,,! ,4
Site Information
a. Dimensions or acreage of lot p
b. Is this a comer lot? AID
c. Will the grade be changed as a result of construction Yes No
d. Public water or Private well --.
e. Sewer or Private Septic System fG..
Value of all work to be performed (labor or materials) $ �6aG
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. 1 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,l or my agents will obtain a certificate of occupancy.
5. 1 also understand that I /we are required to provide an as-built surrey by a licensed land surveyor of all newly
constructed facilities prior to issuance of a certificate of occupancy.have read and agree to the above: PRINT NAME: '�/j'I�-- DATEX/A6
SIGNATURE: DATE
FOR o—mcE usE ONtY
Operating Permit Issued: Yes No
Occupancy Type
Construction Classification
Assembly Occupancy Vmit
Special Conditions
2
Town of Queensbury Building&Codes Principal Structure Application July 2014
Town of Queensbury Thomas R. Van fess
Highway Department. Highway Superintendent
742 Ray Road, Queensbury, NY 12804 Herne: (518) 745-0929
Phone: (518)761-6211
Fax: (518)745-4466 David D►uell
Deputy Highway Superintendent
Home* (§1$)-74 8938 e.
w
DRIV'BWAY PERMIT
mdo 05 '
Irate:
Applicant fame: �r / , ��� � �r :i� � ^ i:iii' "
C Oi l[
Telephone fo.
Address to Be Inspected: � f
Return Address:
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" ( ) 1.5" ( ) 18"
( ) 4„ ( ) 36-
Preliminary inspection completed by: Gate:
Approval by Highway Supt.: (or) Deputy Supt.:
Upon completion please resubmit this approval permit for a final approval.
STEP : ( ) f=inal Approval ( ) Rejected
Date:
Thomas R. Van fess, Highway Superintendent David Duell, Deputy Highway Superintendent
7
Town of Queensbury wilding&Codes Principal Structure Application July 2014