applications Building Permit Application
• 'Down of Quccnsbury—Dept of Community Development, 742 Bay Road, Queensbury, NY
(518) 761-8256
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A permit must be obtained before beginning construction. Permit File No. &O
No inspection will be made until applicant has received a Fce Paid
valid building permit. All applicants' spaces on (his Roc. Tree Pal $ e70
application must be completed and must appear on the Reviewed I3 cat
application form. fEE
?AlO
Applicant:TEE e Owner: SeyME.
Address: 1O 'e,IN Y \ , '� �, Address:
Phone# (151P,)eicAck - & I L Phone ( •
) -
Property Location: Lot Number: I / House Number 3 / Q c_se LM4.
Subdivision Name: ,lJ Tax Map Number:
XNew Building: residence /commercial Estimated Market Value of Construction: $ 3Z`1, a100
o Addition: residence/ commercial •If an Addition, what will use of new addition be?.
❑ Alteration: residence/ commercial •
❑ No change to exterior size: residence/com'l
❑ Other work(describe
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Check Occupancylnformation 1`I Floor 2"Floor • Other floor • Total
Below sq. It. sq. ft. sq. ft. Square Feet •
- i
Single family dwelling 1(.0S°1 1 5 pp 3131
o Two family dwelling
❑ Townhouse
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❑ Multifamily dwelling
#of units •
•
❑ Office •
❑ Mercantile •
o Manufacturing
o 1 car detached garage •
❑ 2 car detached garage
❑ 3 car detached garage •
❑ I car attached garage •
2 car attached garage
501
o 3 car attached garage
❑ Storage building _
commercial
❑ Storage building-
residential
❑ Other
Will any second-hand or ungraded lumber be used? If so, for what? .
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Type of Heating System: electric/ oil /D wood /forced hot air/ baseboard/other:
Number of Fireplaces to be installed I Number of 11'oodstopes to be installed N,A.o
List below the person(s) responsible for supervision of work as regards to building codes: •
Name . Address Phone Number
PlUmbcl' -� � -2
C l�lumhi�c�y _ .-
Mason D F,SOUCI.1e7 PSQX 2.(o . ctizwVtLLE. to32 . cAi
Electrician Del C. goat ?0 Folr +4u1•1T 3(e!j — 2.1 4 e>
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Declaration: please sign below after you have carefully read the statement:
To the best of my knowledge the statements contained in this application,together with the plans and specifications
submitted,are a true and complete statement(Wall proposed work to be done on the.described escribed premises and that all
provisions of the Building Code, the Zoning Ordinance and all other laws pertaining to the proposed work shall he complied
with,whether specified or noted, and that such work is authorized by the owner. Further, it is understood that I/we shall
submit,prior to a Certificate of Occupancy or Certificate.of Compliance being issued, as requested by the Zoning
Administrator or Director of Building and Codes,an As Built Survey by a licensed surveyor;drawn to scale,showing actual
location of all new constructiot
Signature: �: /Jt�r' owner,owner's agent,architect,contractor
Application for Permit—Septic Disposal System
Town of Queensbury 742 Bay Road Queensbury,NY 12804 (518) 761-8256
1. OWNER INFORMATION:
r
3 C3�tt' L`-f -ArKKi E (Lb1-AV.I� Office Use
Location of installation:
Tax Map No. / / I File Permit No.(5(/
"
Owner's Name: . THE MLLP,-tas Ci ZouP E Fee Paid
F
Address: 10 13t_ACaX.SM ITI-1 1) .t V E.. M Aru7 A- , IV Y
2. • INSTALLER'S NAME : PHONE NO.
3. RESIDENCE INFORMATION: (circle year of dwelling, indicate#bedroom(s) and multiply#of
bedrooms with applicable gallons per bedroom to equal total daily flow)
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Year of House: No. of Bedrooms x Computation = Total Daily Flow
' 1980 or older x 150 gal/bdrm =
1980-1991 x 130 gal/bdrm =
1991 —present If x 110 gal/bdrm. = i-2- )e
Garbage Grinder Installed yes / no X
Spa or Hot Tub Installed yes / no X
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4: PARCEL INFORMATION: (circle applicable information&indicate measurements)
To.ography Soil Nature Ground Water Bedrock or Impervious Material Domestic Water Supply
at • lttlit at what depth at wh t depth nic
ipab
•o ling oam ,iJ�/feet r/4-feet well
Steep slope clay if well; water supply
_%slope other from any septic-system
depth: absorption is ft.
other
Percolation Test: (To be completed by licensed professional engineer or architect)
Rate: minute per inch '
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5. PROPOSED SYSTEM: For New Construction: All individual sewage disposal systems must be designed by a licensed
. professional engineer or architect(unless installed in a Planning Board approved subdivision). Add 250 gallons to the size
of the septic tank and leach field for each Garbage Grinder,Spa or Whirlpool Tub.
Septic Tank: 112.5°. gallon(min. size 1,000 gal)
Tile Field: each trench 6'0 ft. Total System Length: 720 ft.
Seepage Pit(s): number of V A size of each: ft. by' ft.
Size Hof Stone to be used: .# /`` / depth or thickness feet
Bed System Size: /1/* x
Alternative System: I/114 length and/or size
6. HOLDING TANK SYST M: (if required)
Number of tanks: N i- / Size of each: gallons /TOTAL Capacity: gallons
Note: Alarm System and associated electrical work must be inspected by a Town approved
electrical inspection agency.
7. SIGNATURE &INFORMATION FOR RESPONSIBLE PERSON(please read)
For your protection,please note that pursuant to Section 136-29 of the Code of the Town
of Queensbury,any permit or approval granted which is based upon or is granted in
reliance upon any material misrepresentation 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 with respect to this application and agree to abide by these and all
requirements of the Town of Queensbury Sanitary Sewage Disposal Ordinance.
V. ' tip
Sign re of responsible person D to
''I'awrt •of (Inee t%bury
5t;wt:ra sttul Sowli ' I)iqpos:t1 Chapter
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Appendix (1 i -
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7. SI NATURE &INFORMATION FO.I�EaYt)N4x.s1. rr„��.�.tram....,..-,. ;;
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Fire,Marshirs.Office Town of Queensbury,742 Bay Road,Queensbury,NY •
(518)761-8205
Application for Fuel Burning Appliances & Chimneys
applicable to solid fuel & vented gas appliances
Date 1'4 Q°fr.c„.►-i , 20 05 Permit No. ; ,-GS ._.l
Application is hereby made to'til uildin T Codr.g-Offrce for'ihe issuance of a Building and Use
Permit pursuant to the New York State Fire Prevention and Building Code. 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 all inspectors to'enter preinises loPerfOrm,required inspections.
NOTE to applicant: Rough-in and Final Inspections are required.
Applicant Information Fuel Burning Appliance Information
(circle appropriate words)
Name: T1-4 e M i C 1-1/ E.t.... C4 F:.ouP Stove: wood coal pellet As.
Fireplace insert
Address: 0 e:A-N.C.tec Ow, E Fireplace, factory-built: wood gas
t I \e' s 17 D?0 Fireplace, masonry: wood gas
Furnace: wood gas oil
Phone: -iat- tl# ``
If non-masonary applicance, please provide
Owner: SA Manufacturer Name:
Address: .Model Number:
Chimney Information
Phone: (circle appropriate words)
Masonry bloc brick stone
;-•- Flue tile ` stee; size: inches
Exact Address: 3 Q ►tom C( e,
of construction or installation Factory-Built
Manufacturer name:
Model Number:
Note: Listed By: Number:
Construction/Installation must
conform to NYS Fire Prevention &Building Indicate(circle) chimney material:
Code. Consult available Town of Queensbuty ,�-----
Handouts.regarding required inspections. Double wall / Triple wall / Insulated / Direct venting
Chimney Liner
Y .,
Csaistizier' .130 .17NEaletarizeutatt--Irolgiurt off'Qaxeertagb9u.ry, ,Ater Yor.
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Fire Marshal Code# $Collected S Ref rnded Received from (refturded to):ji:N\
OD address/ I
A 173 3389 (190);Public Safety
A 233 2655 (230)Minor Sales 8 /
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DATE: -71 111 : 1 \.l l
• - D �
Whitey(Applicant) ''Green(Fire Marshal) / Yellow(Bldg:Dept.) / Pink&Goldenrod(Cashier's Dept.)