applications TOWN OF QUEENSBURY 41110\ \ . REVIEWED BY:
COMMUNITY DEVELOPMENT DEPARTMENT s� - � .:` 1 . - FEE PAID: ad -'
BUILDING & CODE ENFORCEMENT • 0
531 BAY ROAD
QUEENSBURY, NEW YORK 12804 PERMIT. NO. 9.5-h,22
(518) 745-4447
BUILDING PERMIT APPLICATION v3,01213 71
S
A PERMIT MUST BE OBTAINED BEFORE BEGINNING CONSTRUCTION. �:_s\ NS ECTIO1 �
WILL BE MADE UNTIL APPLICANT HAS RECEIVED A VALID BUIL'P G PERMIT.
A11 applicants ' spaces on this application MUST be compl =,!ed ay��. 'ire
signature. of the applicant MUST appear on the application forge01 cr
WH Ot
OWNER OF PROPERTY: /��`/iUie 4 UOn d G1-- �f, % Qu`eenspbep �'
Mailing Address: l }3X (46y r`)U*ei 0. (do , 6 �t'Ia�PP I 1 O, $ , '
Telephoner Number(s) : Work �,f�3 �j • �� Home c� h a cs6
PROPERTY LOCATION: �' -- L j/7-_ � /�[�J� Ica -
Tax Map Numb —Section Block / Lot /p,. i
Subdivision Name:. Lot No. �-_
NATURE OF PROPOSED WORK: ESTIMATED MARKET VA UE OF THE
CONSTRUCTION: $ ()/ 0170
XNEW BUILDING:
RESIDENCE/COMMERCIAL OCCUPANCY INFORMATION:
ADDITION TO BUILDING: P IMARY BUILDING -
RESIDENCE/COMMERCIAL • Single Family Dwelling
ALTERATION TO BUILDING: Two Family Dwelling
RESIDENCE/COMMERCIAL Family Dwelling
(NO CHANGE TO EXTERIOR SIZE) Office
OTHER WORK (DESCRIBE BELOW) Mercantile
Warehouse
Manufacturing
Other
GROSS AREA OF PROPOSED STRUCTURE:
1ST FLOOR 4 (JO SQ. FT.
IF ADDITION, USE OF NEW ADDITION:
2ND FLOOR. . SQ. FT.
u
OTHER FLOORS SQ. FT. .,.. `
(not unfinished cellar or basement) ACCESSORY BUILDINGS:
Detached Garage - One/Two Car
TOTAL FLOOR AREA: /ci ip � SQ. FT. Attached Garage - One/Two Car
Private Storage Building
. SIZE OF NEW STRUCTURE: 'Commercial Storage Building
Other
--( FEET X '- -:t FEET
•
Foundation Type: --Poured ?(rek Will any second-hand or ungraded
Number of Stories: 1 lumber be used? : If so, for what?
(habitable space only) C1 .
Height (grade to ridge) : feet Type of eating System:
Number of fireplaces: and/or woodstove (circle all ich applies)
to be installed: 0 Electric / Oil / Gas / Wood
Force of j/ Baseboard / Other
-PERSON RESPONSIBLE FOR SUPERVISION OF WORK AS REGARDS., TO BUILDING CODES IS:
` •
NAME OF BUILDER/ADDRESS/PHONE: C�1, 4e_c . .. ,
NAME OF PLUMBER/ADDRESS/PHONE:
NAME OF MASON/ADDRESS/PHONE:
NAME OF .ELECTRICAN/ADDRESS/PHONE: 17 - Y-7 7
DECLARATION.. _ _ _--- — -=_ -
To the best of my knowledge the statements contained in this appli-
cation, together with the plans and specifications submitted, are a true
and complete statement of all proposed work to be done on the described'
premises and that all provisions of the Building Code, the Zoning Ordinance
and all other laws pertaining to the proposed work shall be 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, an AS BUI PLOT P A
drawn to scale, showing actual location of r-,o'ect on prema.se
Signature o 7
(Owner, owner' s agent, a itect, contracto
FOR ANY SPECIAL PROVISIONS - SEE REVERSE SIDE:
1993�4)�112 73 476,-- '�f 4�� 0�,
TOWN OF QUEENSBURY h� T >m
APPLICATION FOR SEPTIC DISPOSAL PERMIT rmit c3
e P, ;dCeived o
P Town of
ueensbury Al
ridg.Dept
Date: r 0 i / Iq5 Revi �:d By 44;
LOCATION OF PROPERTY FOR INSTALLATION: P1oo ) , Il b ) eel,
Owner's Name: P 'tJe ijr\&7. Le 11„.4
Owner' s Mailing Address: 121-1 B.a( ? 11( GY4 .411e/ 00C,P-65b,-/Ifyitl
Installer' s Name: _ e_ k=-AuAz1y_5�,
Phone ''-tiat9/123
Number of bedrooms (if ,residential ) :
Total daily flow (residential-compute @ 150 gal . per bedroom) : '. Ot ce-T
Topography-Circle One: Flat Rolling Steep Slo e % of Slope 7~—' --
Soil Nature-Circle One: Sand Loam Clay Other /Depth:
Ground Water-At What Depth? Feet
Bedrock or Impervious Material-At What Depth? Feet
Percolation Test-Circle One: Not Required Required/Rate Min. Per Inch
Domestic Water Supply-Circle One: Municipal Well Other
If domestic water supply is a well -
Separation: Water supply from any sep 63 c ?absorption /• feet
/Z�St3 P
PROPOSED SYSTEM: Septic Tank JE gal . (Minimum size: 1_,000 gal .;)
--i:a2
Tile Field: Each Trench co feet//Total System Length / feet
Seepage Pit(s) : Number of / Size each: ft. x ft.
Size of Stone to be used: # / Depth or Thickness feet
**************
HOLDING TANK SYSTEM IF REQUIRED
No. of Tanks Size\of Each Gal .
Alarm system and associated electrical work to be inspected by a certified
agency.
****************
I have read the regulation on the revelrse side of this sheet and agree to abide
by these and all requirements of the/Town of Quee -sbury Sanitary Sewage Disposal
Ordinance.
SIGNATURE OF RESPONSIBLE PERSO , / V • . ' DATE: 0417,43