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PRINCIPLE STRUCTURE PERMIT
Permit Fee: 3Lt 7,J,� 6,3,oe) 5D a .
APPLICATION
Town ofQueensbui-'v *Rec Fee: 7� V
742 Bay Road,Queensbury,NY 12804
P: 518-761-8256 www.gueensbury.net Invoice #: 2l//91
Project Location:
Tax Map ID /0 - yo Subdivision Name:/
*TOWN BID. RESOLUTION 86-2013: $850 recreation fee for new dwelling units: single family,duplexes/two-family,
multiple family, apartments, condominiums, townhouses, and/or manufactured & modul k—irroas,
homes. This Is In addition to the permit fee(s). E 0 V E
CONTACT INFORMATION: NOV 15 2017
9 Applicant: TOWN OF QUEENSBURY
Name(s): /1W_zJ _ZJV�_ COMMUNITY DEVELOPMENT
MailingAddress, C/S/Z:
Z!�Iuf xv
Cell Phone: ) II
Land Line:
Email:
" Primary Owner(s):
Name(s):
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
9 Contractor(s):
Business Name: 09
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
® Architects Fngsneer
Business Name:
Contact Name(s): /�)A A'/' U V
Mailing Address, C/S/Z:
Cell Phone: Land Line: '7z 6
Email:
Contact Person for Building &_Code ompliance:
Cell Phone: —( Land Line:
Email:
Town of Queensbury Building&Code Enforcement Principle Structure Application Revised February 2017
DECLARATION:
N
1. I acknowledge that no construction shall commence prior to issuance of a valid b u i I ding permit and
work will be completed within a 12 month period.
2. Ifthework is not completed 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 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. 1 acknowledge that prior to occupying the facilities proposed I, 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.
I have read and agree to the above:
PRINT NAME:
SIGNATURE: DATE: I
Town of Queensbury Building&Code Enforcement Principle Structure Application Revised February 2017
Town of Queensbury Thomas R. Van Ness
ighway Superintendent
i i
Highway �' -�_� 1 Home (518) 745-0929
Department
NOV 15 2017
742 Bay Road—Queensbury, NY 12801 David Duell
518 761-8211 TOWN OF QUEENSBU_F� y Highway Superintendent
Phone:
( COMMUNITY DEVELOP
Fax: (518) 745-4466 ome (518) 743-0938
DRIVEWAY PERMIT
DATE: r /
APPLICANT NAME: /h t' &11"Jei /yll wme— )
TELEPHONE NO.: l 3K e1gyZ/
ADDRESS TO BE INSPECTED:
RETURN ADDRESS: w e
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
r = FUEL BURNING APPLIANCE & Office Use Only
CHIMNEY APPLICATION Permit#:
��(-� , (� �/] i fee:$ 7 v
linen of c 11ccnslu n. `U' t! V
742 Bay Road, Queensbury, NY 12804 i c' :#: ���
P: 518-761-8256 www.gueensburV.net NOV 15 2017
TOWN OF QUEENSBURY
C ITY DEVELOPMENT
Project Location: DC ��, U Tax Map
Room of Install: Planned Install Date: l Is
le
**ONE APPLICATION PER APPLIANCE**
CONTACT INFORMATION:
• Applicant: �.
Name(s): �—
Mailing Address, C/S/Z: Za!2 10-I'd Z
Cell Phone: ( 5�/ ) - L' Land Line:
Email:
• Primary Owner(s):
Name(s):
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line: _( )
Email:
• Installer Builder:
Business Name:
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: _( l� ) eijc 0 Land Line: _( )
Email:
Contact Person for Building & Code Compliance: A 6mz
Cell Phone: _(,fLand Line: _( )
Email:
Fuel Burning Appliance &Chimney Application Revised March 2017
FUEL BURNING APPLIANCE INFORMATION:
TYPE OF DEVICE:
Stove _ Fireplace Insert / Fireplace
Fuel Fired Equipment (Garage Only, 18" clearance per IMC 304.3)
Fireplace, factory built** 2
**Manufacturer's name: L!� d'41U Model #: �'i
SOURCE OF HEAT:
Wood Coal Pellet Gas
CHIMNEY INFORMATION:
Masonry:
block brick stone
Flue:
_tie _steel _size, in inches
_Material*:
/double-wall _triple-wall_insulated
(*Manufacturer's name: /7,a,Pvr'A��'r )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:
PRINT NAME:
SIGNATURE: DATE:
Fuel Burning Appliance &Chimney Application Revised March 2017
SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
742 Bay Road,Queensbury,NY 12804
Ibnn rcL,rcn.vhui;r
P:518-761-8256 www.gueensbury.net Permit#:
Tax Map ID#: g G Permit Fee: $ ; Invoice#:
Project Location: �/� �1{�,S/L� � �� �3 Septic Variance? Yes No
r
Primary Owner(s)
Mailing Address �G
Phone & Email �� 1�•� l�
Installer/Builder �!
Mailing Address
Phone & Email J �9
Engineer
.11 .
Mailing Address t6(/ `1
Phone & Email
Contact Person for Building&Code Compliance: Phone:
�i�'.li Phone: 1�-
RESIDENCE INFORMATION:
Year Built #of bedrooms X gallons per bedroom =total daily flow Garbage Grinder Yes No
1980 or older Installed? (circle one)
1981-1991
Spa or Hot Tub Yes No
Installed? (circle one)
1992-Present 7� G
PARCEL INFORMATION:
Topography at Rolling Steep Slope %Slope
Soil Nature Sand Loam Clay Other
Groundwater At what depth?
Bedrock/Impervious material At what depth? A
Domestic Water Supply ZMunicipal _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 f'I 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 2f7-0 ft.; Each Trench > ft.
Seepage Pit with#3 stone How many: ; Size:
Alternative System Bed or other type:
Holding Tank System I 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. ��
PRINT NAME: zr//) L%����{ 'C�- DATE: I�
SIGNATURE: DATE: l/ /
Town of Queensbury Building&Code Enforcement Revised February 2017