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applications PRINCIPAL STRUCTURE APPY CATION Office Use Only �j s DATE Received Tax Map ID TAX MAP ID ��• ,� _ � " Permit No. l?C-ccC� l Permit Fee ZONING Rec Fee s► b -19 Site Plan# HISTORIC SITE Yes No Subdivision # SUBDiyisioN NAME 74h Q. P"'? Lot# TowN BD.RESOLUTION 8$-2013: $850 RECREATION FEE FOR NEW DWELLING UNITS,INCLUDING SINGLE FAMILY DWELLINGS,DUPLEXES OR TWO FAMILY DWELLINGS, MULTIPLE FAMILY DwELLINGS, APARTMENTS, CONDOMINIUMS, TOWNHOUSES, AND/OR MANUFACTURED & MODULAR HOMES, BUT NOT MOBILE HOMES_ THIS IS IN ADDITION TO THE PERMIT FEE. APPLICANT Aelil),L �&////-I _ OWNER ADDRESS X I fk / ADDRESS PHONE/E-MAIL f% PHONE/E-MAIL CONTRACTOR COST OF CONSTRUCTIO'N/ ESTIMATED): $110, 000j ADDRESS_ BUILDING ADDRESS: PHONE/E-MAIL �p / �g (7 CONTACT PERSON FOR BUILDING&+CODES COMPLIANCE: �-C��� _ _,—PHON / HCl - TYPE OF CONSTRUCTION Check all that apply Please indicate measurements as required below New Addition Alteration yeti floor sq. ft. 2"d floor sq.fit. Total sq,ft. Height ef Single Family Two-Family Multi-Family (# of units---) Townhouse ;WN 16 2016 Business Office Retail - Mercantile Factory- Industrial Attached Garage (# of Other 1 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) Gas Oil Propane Solar Other Fireplace: complete a separate application for Fuel Burning Appliances& Chimneys Are there structures not shown on plot plan? Are there easements on the property'?' Site Information a. Dimensions or acreage of lot , b. Is this a comer lot? 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 Value of all work to be performed(labor or materials) $ ---- 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, pians 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,t or my agents will obtain a certificate of occupancy. 5. 1 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. 1 I have read and agree to the above: PRINT NAME: i' DATE i t SIGNATURE: DATE _ F_0R OF_7cE uSg oNL Operating Permit Issued: Yes No Occupancy Type Construction Classification Assembly Occupancy Limit Special Conditions 2 Town of Queensbury Building&Codes Principal Structure Application July 2014. Town of Queensbury Thomas R. Van Ness Highway Department Highway Superintendent 742 Bay Road,Queensbury,NY 12804 Home: (518) 745-0929 Phone: (518)761-8211 Fax: (518)745-4466 David Duell Deputy Highway Superintendent Home: (518)745-0938 DRIVEWAY PERMIT Date: 16AK A Applicant Name: f Telephone No.: 6 /f Z%__,_ Address to Be Inspected: rf Retum 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 O Slight Swale ( ) Deep Swale .11IN 16 2016 ( ) Level with the road { ) Level with the top of the paved wing Size culvert pipe to be used(if necessary) ( ) IT ( ) 15" ( ) 18" ( )24" ( )36" Preliminary inspection completed by: Crate- Approval by Highway Supt.: ;(or)D$pty Supt. . . Upon completion please resubmit this approval permit fora final.approval. STEP 2: ( ) Final Approval ( )�tejebted Date: Thomas R.Van Ness,Highway Superintendent David puetl, Deputy Highway Superintendent 7 Town of Queensbury Building&Codes Principal Structure Application July 2014 Fuel Burning Appliance & Chimney Application office Use Only Received DATE: Tax Map ID TAX MAP ID: Permit No. Permit Fee ZONE: OWNER PHONE/E-MAIL , © Z� ADDRESS al d— AW Zi INSTALLER/ PHONE/E-MAIL BUILDER G- /� �F/aloe-- CONTACT PERSON FOR BUILDING&CODE COMPLIANCE: PHONE/E-MAILBUILDING ADDRESS ROOM OF INSTALL: Z&6// PLANNED INSTALL DATE: '' FUEL BURNING APPLIANCE INFORMATION WOOD COAL PELLET GAS OIL NOTE: ROUGH-IN& STOVE FINAL INSPECTION ARE FIREPLACE INSERT REQUIRED. FIREPLACE,FACTORY BUILT` NOTE: MANUFACTURER'S FIREPLACE,MASONRY INSTALLATION MANUAL FURNACE(GARAGE ONLY) MUST BE AVAILABLE AT TIME OF INSPECTION *If factory built provide manufacturer name: Model#: Listed by: Number: j1 IN 6 CHIMNEY INFORMATION Masonry" (check one) BLOCK BRICK STONE Flue' TIE STEEL Size in inches Material DOUBLE WALL PLE WALL INSULATED ** If non-masonry provide manufacturer name: /L— ;Model #: 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 inspector's to enter premises to perform required inspections. I HAVE READ AND AGREE TO THE ABOVE: PRINT NAME: o &"M—e DATE: fA SIGNATURE: DATE: lI Town of Queensbury Building&Codes Principal Structure Application Revised September 2014 SEPTIC DISPOSAL PERMIT Office use aft �116/ DATE ; l: Received tp Tax Map ID TAx MAP 1D j 1 I P�r t�t // Permit ee LoCATfoNOFINSTALLATION /�� L J � Approvals: APPLICANT iL U f� PHONFI E-MAIL ADDRESS Z INSTALLERIBUILDER: !_ h1 4A",/ % �+C. ZA71AA_. / PHONE/E-MA1L ADDRESS: OWNER !�I?_..#X-e l� - PHoNEI EMAIL�J�'y'7'► Address �j / CONTACT PERSON FOR BUILDING&CODES COMPLIANCE: . IrYv Ll l� "_d PHONE_� 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 Not Tub installed Y N 1992-Present Zk O6 PARCEL INFORMATION Topography Flat rolling Steep slope %slope Soil Nature Sand Loam Clay Other Groundwater At what depth? am Bedrock/Impervious Material At what depth? 440 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 engineering/architect) PROPOSED SYSTEM FOR NEW CONSTRUCTION Tank Size 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 7,02 ft.;Each trench x D Seepage Pit with#3 stone Now many; —;size Alternative System Bed or other type? Holding Tank System Total required capacity? Tanis size #of tanks Notes: 1)Alarm system&associated electrical work must be inspected by a Town..approvedalectrical 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. DECLARATION: Any permit or approval granted which is based upon or is granted In rellance upon any material representation or failure to maize 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 the!WX all quirements of the Town of Queensbury Sanitary Sewage Disposal Ordnance. Print Name: Date: Signature: Date; 6 Town of Queensbury Building&Codes Principal Structure Application July 2014