2004-003 iAMINA, TOWN OF QUEENSBURY
FAT
742 Bay Road,Queensbury,NY 12804-5902 (518) 761-8201
Community Development - Building & Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20040003 Date Issued: Thursday, January 27, 2005
This is to certify that work requested to be done as shown by Permit Number P20040003
has been completed.
Tax Map Number: 523400-296-007-0001-012-000-0000
Location: 653 BAY Rd
Owner: ADIRONDACK MANOR HOME FOR ADULTS
Applicant: ADIRONDACK MANOR HOME FOR ADULTS
This structure may be occupied as a:
By Order of Town Board
Septic Alteration Commercial TOWN OF QUEENSBURY
JG
Director of Building&Code Enforcement
TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
107:0
Community Development-Building&Codes (518)761-8256
BUILDING PERMIT
Permit Number: P20040003 Application Number: A20040003
Tax Map No: 523400-296-007-0001-012-000-0000
Permission is hereby granted to: ADIRONDACK MANOR HOME FOR ADil,TS
For property located at: 653 BAY Rd
in the Town of Queensbury,to construct or place
at the above location in accordance with application together with plot plans and other information hereto filed
and approved and in compliance with the NYS Uniform Building Codes and the Queensbury Zoning
Ordinance. Type of Construction Value
Owner Address: ADIRONDACK MANOR HOME F
653 BAY Rd Septic Alteration Commercial
Total Value
QUEENSBURY, NY 12804-0000
Contractor or Builder's Name /Address Electrical Inspection Agency
I.B.S. SEPTIC
`rl
2 LOWER WARREN STREET
OI TEENSBI TRY_ NY
Plans&Specifications
2004-003 COMMERCIAL SEPTIC ALTERATION
$35.00 PERMIT FEE PAID -THIS PERMIT EXPIRES: Thursday, February 10, 2005
(If a longer period is required,an application for an extension must be made to the code Enforcement Officer
of the Town of Queensbury before the expiration date.)
Dated at the Town of Queensbury; Monday, January 05, 2004
SIGNED BY for the Town of Queensbury.
Director of Building&Code Enforcement
Application for Permit—Septic Disposal System
/ Town of Qllee'nshiuy7.1213ayRoad Queensbiirv, NY 12804 (5 lb) 761-8256
1. OVER INFORMATION:
I
Location bf installation: 653 Bay Road Of(icc Use
Filo Permit No. ON Iwy :!
Tax Map No. 296.7/ 1 / 12 1�
Fee Paid 3 O4)
Owner's Name:
Adirondack Manor — Home for Adults �'
Address: 634 Plank Road, Suite 102
Clifton Park, NY 12065
2. INSTALLER'S NAME : IBS Septic PHONE NO._V 1. /C
D
3. RESIDENCE INFORMATION: (circle year of dwelling, indicate 11 bedroom(s) and multiply II of I V G
bedrooms with applicable gallons per bedroom to equal total dailyflouJAN 0 2 2004
Year of House: No. of Bedrooms x Computation = Total Dail Flor_vTowN OF QUEENSBURY
BUILDING AND CODE
1980 or older x 150 gal/bdrm =
1980— 1991 x 130 gal/bdrm =
1991 —present x 110 gal/bdrm =
Garbage Grinder Installed yes / no BASED ON EXISTING WATER USE
Spa or Whirlpool Installed yes— / no
4. PARCEL INFORMATION: (circle applicable information & indicate measurements) SEE PLANS
TopogtlI.p liy SQiI N_attir9 crpu„d Water Bedrock or impervious Material Domestic Water Supply
Nat sand at what depth at what dchth municipal
Rolling loam fret fret 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
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'Fob. SEE PLANS
Septic Tank: gallon (min. size 1,000 gal)
Tile Field: each trench - ft. Total System Length: __fl.
Seepage Pit(s): number of size of each: ft. by ft.
•
Sizo of Stone to be used: lI / depth or thickness fret
Bed System Size: x
Alternative System: length and/or size
•
6. HOLDING TANK SYSTEM: (if required) N/A
Number of tanks: / 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 re!ulations with respect to this application and agree to abide by these and all
requirements of 1 ,
W +wn of Queensbury Sanitary Sewage Disposal Ordinance.
`� r 2 °¢
Signat : of responsible person ate
F
f
Town of tltic:eftybury
,Sewers :end Sewage Disposal (:haI)ier
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Septic Inspection Report
Office No. (518)761-8256 Date Inspection req. - e zv:•:
Queensbury Building&Code Enforcement Arrive: a . ►epart: am/pm
742 Bay Rd.,Queensbury,NY 12804 Inspector's Initials:
2CC . -- tC
-27
NAME: IADtQc.). n M rs>c-)P_ P, RMITNO.:
LOCATION: ((-y ) SPECT ON: `
RECHECK:
•
Comments and/or diagram
Soil Type: Sand/Loam/Clay
Type of Water: Municipal/Well Water
Waterline separation distance ft.
Well separation distance ft.
Other wells: ft.
Absorption Field: Total length ft.
Length of each trench ft.
Depth of trenches ft.
Size of Stone
Seepage Pits: Number
Size: x
Stone Size:
•
Piping Size Type
Building to tank _
Tank to Distribution Box
Distribution Box to Field/Pit
Opening Sealed: Y/N/Partial
Location I Separations
Foundation to tank ft.
Foundation to absorption ft.
Separation of Pits ft. C (\L r j \L:-
Conforms as per Plot Plan -Y—N
Location of System on Property:
Front Rear Left Side Right Side
Middle Front Middle Rear
System Use Stairs:
Approved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
L:\SueHemingway\Building.Codes.Inspection.FORMS\Septic Inspection Report.doc January 28,2003
•
Septic Inspection Report
Office No. (518)761-8256 Date Inspection re st c ' e :
Queensbury Building&Code Enforcement Arrive: A part: \\".lim
742 Bay Rd.,Qu ensbury,NY 12804 Inspector's Initial •
NAME: ? £TON:
NO.: a 4 oo.?
.. '•
LOCATION: - 0 11
RECHECK:
Comme.is and/or diagram
Soil Type. Sa . oa-a/Clay
Type of V6 'cipa /Well Water
Waterline separation istance ft. L.,vc.riciz. 0.
Well separation distance ft.
Other wells: _ft. 1\( )FSTH , ) Q.
Absorption Field: Total length V-1—k ft.
Length of each trench \c(,'7l ft.
Depth of trenches -'?� ft. Mc
Size of Stone ‘t 1'L - `Oes.\-a'Z 1_ (E
Seepage Pits: Number h-
LO
Size: x
Stone Size: 1 (C.
Piping Size Type
Building to tank `L 1 w b
Tank to Distribution Box L-I Q'-rj
Distribution Box to Field/Pit y-l 'I ,�� ti
Opening Sealed: Y/N/Partial
/ \
Location/Separations C\'
Foundation to tank - �----it
Foundation to absorption / ft.
f .
Separation of Pits ft.
Conforms as per Plot Plan Y_N"
Location of System on Propekty:
e
i
Front Rear Left ide Right Side
Middle Font ddle Rear Ikl--) E.Q.._ _ \t. ..... .Q_'t_i VL Ri
S stem Use S tus•
proved
/Partial Approved and needs to be re-inspected,please call the Building&Codes Office
,.;` Disapproved
G4SueHemingway\Building.Codes.Inspection.FORMS\Septic Inspection Report.doc January 28,2003
6
Septic Inspection Report
Office No. (518)761-8256 Date Inspection re, - eceiv
Queensbury Building&Code Enforcement Arrive: :m/p• ►. ..rt: 2. a p
742 Bay Rd., Queensbury,NY 12804 Inspector's Initials: ///
NAME: A n% C- A.Le t--14\0 v. IT NO.: ' --`9 Ce`
LOCATION: V)A" V-- SPELT ON: 1 2 '--\
RECHECK:
• Comments and/or diagram
Soil Type: Sand/Loam/Clay
Type of Water: Municipal/Well Water
Waterline separation distance ft.
Well separation distance ft.
Absorption Field: Total length F%Fi D 'Z • ft.
Len, h of each trench1111 v ft. —�! D1-i
De•th of trenches _ ! _ _ ft. Eaopku
__ _
Size of one
Seepage Pits: Number \0 1��-CRF tjR
Size: x
•
Stone Size:
Piping Size Type (y 'To C3 /1- Fi` i .. -)
Building to tank ;�jU1
Tank to Distribution Box F'\Distribution Box to Field/Pit +
Opening Sealed: Y/N/Partial
Location/Separations
Foundation to tank ft._ \c) c,J 1P\ \--T ot, J6
Foundation to absorption ft.
Separation of Pits ft.
/
Conforms as per Plot Plan �/Y N
Location of System on Property: �A�T\AL
Front Rear Left Side Right Side
Middle Front Middle Rear
System Use Status:
/ Approved
J Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
L:'\SueHemingway\Building.Codes.Inspection.FORMS\Septic Inspection Report.doc January 28,2003
r. t...........................................................................,
Town of Queensbury ci &
0 ,01
(11, Fire Marshal's Office .�- vet--
742 Bay Road '1 trq e I v't v1.G
Queensbury, NY 12804
Phone (518)781-8205 FaX(518) 745-4437 I/
Fire Marshal's Inspection Report
Request SCHEDULE
Received: __ __Permit# &o 0 4 —�o9 INSPECTION ON:_„- .' �
,�"
' '7
Name: / (A_, UiA,l ) A 0 NYTIME
Location: iA i of l oil (flt1
APPROVED
_.____..T.N/A YES NO COMMENTS
EXITS
AISLE WIDTHS
EXIT SIGNS_BATTERY µ -- v
c o �� ���L
EMERGENCY LIGHTING All 4
FIRE EXTINGUISHERS X
FIRE ALARM SYSTEM _ �_ _
FIRE SPRINKLER SYSTEM
_____
FIRE SUPPRESSION SYSTEM
HOOD INSTALLATION }_
_-
INTERIOR FINISHES �- OK C/ �, L`
STORAGE ��
COMPRESSED GAS _.,
CLEARANCE TO SPRINKLERS
CLEARANCE TO HEATING
UNITS _
CLEARANCE TO ELECTRICAL w
REQUIRED SIGNAGE
EMERGENCY PLAN
MAXIMUM OCCUPANCY SIGN
CHIMNEY
MASONRY ROUGH IN
FINAL
CHIMNEY
FACTORY BUILT ROUGH IN
FINAL •
WOOD
STOVE _T ROUGH IN
FINAL --._,j
VENTED GAS
APPLIANCE ROUGH IN
FINAL
FIREPLACE
—�
MASONRY ROUGH IN OK T 11 DATE OK FOR CO NOT OK
ANAL �
FIREPLACE �,
.-
FACTORY BUILT ROUGH IN _. INSPEC BY
____. FINAL •
COMDEviCHRISJMIORD,LETTERS2Q01IFIREMARSHALINSI;'ECTIONREPORT 1102200/
WHITE-BUILDING DEPARTMENT COPY YELLOW-OCCUPANT COPY
.e.
• 6111
Town of Queensbury
Fire Marshal's Office 9 )(D
742 Bay Road
Queertsbuiy,NY 12804
LPhone (518)761-8205 Fax(518) 745-4437
Are Marshal's Inspection Report 30. 0 Li - 0C25
Request ,00)01-1 __ ,
S SCHEDULE )
- /5-
Received: Permit# (-X) INSPECTION ON: 1 9 -
Name: A--'S-K2---Aarl_ic 3;00 AM I:( 41) ANYTIME
Location:
APPROVED
______.
N/A YES NO - COMMENTS
EXITS j
AISLE WIDTHS -I-
.14 e-K.; 5YA)
EXIT SIGNS-NORMAL
- BATTERY e irvai (icor.
EMERGENCY LIGHTING ,,,
FIRE EXTINGUISHERS I\ - ri‘V)flifi frkfL,0 A15'C
1 6?kd -Pio_
FIRE ALARM SYSTEM 4 , _ I I
FIRE SPRINKLER SYSTEM
FIRE SUPPRESSION SYSTEM '
HOOD INSTALLATION A. ‘[.- (
eX /A/T{151{01i -5 7b, miAhmum
)
INTERIOR FINISHES X
STORAGE X -
COMPRESSED GAS- - - X - i
CLEARANCE TO SPRINKLERS Ta -- - 0(19' 59 At 5 0 Al 5A (e 5
CLEARANCE TO HEATING -
UNITS
-000 ( A/aid b utb5 -CLEARANCE TO ELECTRICAL
REQUIRED SIGNAGE
EMERGENCY PLAN
MAXIMUM OCCUPANCY SIGN A
CHIMNEY
MASONRY ROUGH IN
FINAL •
_
CHIMNEY 1
FACTORY BUILT ROUGH IN
FINAL
_
WOOD
STOVE ROUGH IN
FINALL I
VENTED GAS
APPLIANCE ROUGH IN
FINAL
FIREPLACE
MASONRY ROUGH IN
OK THIS DA - FORTCO NOT OK
FINAL
FIREPLACE — .e_ _ -
FACTORY BUILT _ ROUGH IN
' V-ejtc7--. NSPE
FINAL
COIVIDEV/CHRISJIWORD/LETTERS2001IFIREMAFtSHALINS CTIONREPORT11022001
WHITE-BUILDING DEPARTMENT COPY YELLOW-OCCUPANT COPY
1--R-e AM
cEk
Septic Inspection Report
Office No. (518)761-8256 Date Inspection request received: '
Queensbury Building&Code Enforcement Arrive: arn/itim Depart: am/pm 00 3
742 Bay Rd., Queensbury,NY 12804 Inspector's Initials:
NAME: R 1 ;0 1AC , iNt ptr:.,U PERMIT NO.: C..L; 1-k cjL01 t,1)
LOCATION: {VL{ () An INSPECT ON:
RECHECK: EPA
Comments and/or diagram
Soil Type: Sand/Loam/Clay 1
Type of Water: Municipal/Well Water
Waterline separation distance ft. � �' - 0 u1 (t3
Well separation distance ft.
Other wells: ft. RO 612e-s 5 T<
Absorption Field: Total len.th ft.
Length of each trench ft. \
Depth of trenches ft.
Size of Stone
Seepage Pits: Number
Size: _x_
Stone Size:
Piping Size Type
Building to tank
Tank to Distribution Box
Distribution Box to Field/Pit
Opening Sealed: Y/NI Partial
Location/Separations
Foundation to tank ft.
Foundation to absorption _ _ft.
Separation of Pits ft.
Conforms as per Plot Plan Y—N
Location of System on Property:
Front Rear Left Side Right Side
Middle Front Middle Rear
System Use Status:
Approved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
L:'\SueHemingway\Building.Codes.Inspection.FORMS\Septic Inspection Report.doc January 28,2003