applications Building Permit Application •
Town of Queensbury-Dept of Community Development, 742 Bay Road,Queensbury,NY
(518)761-8256
A permit must be obtained before beginning construction. Permit File No. 00 4-1-0%
No inspection will be made until applicant has received a Fee Paid 3
$ i
valid building permit. All applicants' spaces on this Rec.Fee Paid $
application must be completed and must appear on the Reviewed By:
application form,
Applicant: w I L L.k,cNM ni/130n1 Owner: M Ic PIA c.,- /Y,b S.,o i i M M c.0 Anon/
Address: 4o a-iT h&vsf: Qo Address: s)- wCsT[,A,2Y f1JC
C.LCoc Z QA LE . ^► r r 2 r?�1 o j 1 A Y ErJ I S 4-4.- Q 1 i y io 3O
Phone#( )E, - c5'3 Phone#(a) d73 - IS9a.
Property Location: Lot Number: / House Number 2 c / (f1Y1/4)6 A p,2 Z. •
Subdivision Name: Tax Map Number: g 3 cl. (3 - i -'-/
)( New Building: Cresidence hcommercial Estimated Market Value of Construction: $ 9Oof yoo
a Addition: residence-7 commercial If an Addition,what will use of new addition be?
❑ Alteration: residence/ commercial
a No change to exterior size: residence/com'l
a Other work(describe
Check Occupancylnformation 1"Floor 2' Floor Other floor Total
Below sq.ft. sq.ft, sq.ft. Square Feet
A Single family dwelling .16 v h E. c' / 5 3 6
a Two family dwelling
a Townhouse
a Multifamily dwelling
#of units
a Office
a Mercantile
a Manufacturing
a 1 car detached garage RECEIVED
2 car detached garage
a 3 car detached garage
a 1 car attached garage •J Li N 1 2 2004
a 2 car attached garage
a 3 car attached garage K)VdN or gND COU Y
a Storage building- Bur]11�10AND CODE
commercial
a Storage building-
residential •
a Other i .
What is the proposed height of the structure 3-1 feet _inches
Will any second-hand or ungraded lumber be used? If so,for what?
Type of Heating System. electric oil / gas/wood /forced hot air/ ase oar bother:
Number ofTirevlaces to be installed / Number of Woodstoves to be installed 0
List below the person(s)responsible for supervision of work as regards to building codes:
Name Address Phone Number
Builder 111rtUrioty VE n1(0. I►J L. do 6c,:;,ha•-)J k 20 Cti,k,toicc 511/48 . 6%, y57 3
Plumber No'ilit 4.1 M6 t . _ (novae-).) t -JO Q r Sig, ---y 5 - 1 s3 ?
Mason . FIL-Elc. Mi7c' RI 3 MILToi) p,2. sbr- 5o3 . ry3 - '39y
Electrician OCNt►,> G.11-1E2 13 •rwi�,,rcio0 L,. L26y SIg -. -a 960
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 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, as requested by the Zoning
Administrator or Director of Building and Codes,an As Bulls Survey by a licensed surveyor;drawn to scale,showing actual
location of all new
Aco�truction.
Signature: ;i/ K.- - '�2t___ 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:
Location of installation: 3o C '�� ��, -. 7--.-.---.-.. -Of fice Use ._._-..--•-..-.....--
CCEoE��1�-f ce
Tax Map No. 3iy.A / Air '? File Permit No - 1
Owner's Name: M 1114\� -- (WO p►TM Fee Paid
M LMA Ho nl
Address: Sa kVESTgt.3R: AUE S "" -"-'.-�------ ..-
r___ is�n,.r N
2. INSTALLER'S NAME : W i cA-,,ye-. MqYo,.1
3• RESIDENCE INFO PHONE NO, gt is - 621_9S 7.f
RMATION: (circle year of dwelling, indicate#bedroom(s) and multiply#of
bedrooms with applicable gallons per bedroom to equal total daily flow)
•
°use. No of Bedrooms
x atatipn =
1980 or older w
1980- 1991 x 150 gal/bdrm
1991 -present x 130 gal/bdnn =
x 110 ga1/bdrm = 3 3 0
Garbage Grinder Installed yes 40.. / no
Spa or Hot Tub Installed yes / no
4• PARCEL INFORMATION: (circle applicable information&indicate measurement
s)
T o a h oil Nature Ground Water Bedrock or Im ervio •
l sand at what de th at o ' W
Rolling -Fa- P at what depth 1
Steep slope 6 ` 3 6�" municipal
�•L'' well
%slope other if well; water supply
depth; from any septic-system
Percolation Test: (To be completed by licensed professional engineer or archit absorption is ft•
other tl»o_i�'ticd►
Rate: 110 minute per inch •
ect)
1
5. PROPOSED SYSTEM: For NeN r2„�.,....,•___,
professional engineer or architect(unless installed in a Planning Board approved subdivision).°`�u�uon. All individual sewage disposal systems must be designed by a licensed
Add 250 gallons to the size
of the septic tank and leach field for each Garbage Grinder, Spa or Whirlpool Tub.
Septic Tank: I Ood gallon /--_ (min. size 1,000 gal) �j(/S rs,)
Tile Field: each trench 50 ft, Total System Length: - ' 2 SO
Seepage Pit(s): number of N A
size of each: ft. by
Size of Stone to be used: # �
/ a / depth or thickness of
feet
Bed System Size:
x _
Alternative System:
length and/or size
• ANK SYSTEM: (if required)
Number of tanks: / Size o
gallons /TOTAL Capacity:
Note: Alarm System and associated electrical work must be inspected by a ov gallons
electrical inspection agency. ed
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 anted which is based reliance upon any material misrepresentat granted in
on or failure to make a material fact or
circumstance lcnown 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 a
requirements of the Town of Queensbury Sanitary Sewage Disposal Ordinance. 11
4d2f.,. je,..__,
Signature of responsib e person 2 a
Da e
Fire Marshal's Office Town of Queensbury,742 Bay Road,Queensbury,NY
(518)761-8205
Application.ifor-1Fuel Burning Appliances & Chimneys -
applicable to solid fuel & vented gas appliances •
. rx •
1, r
Date l 'v.C.CM B a.. 3o 20 0 Permit No. C�-1�_ .;t- _ 1 `t I
. Application is hereby made to the Building-& Codes Office for the 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 premises to performrequired inspections.
NOTE to applicant: -Rough-in and Final Inspections are required.
Applicant Information Fuel Burning Appliance Information
(circle appropriate words)
•
Name: rl f. -,;,,t riF-'► MA ..2,';'.Yiki i bOs I) ie4 C. Stove: wood .coal pellet gas
Fireplace insert
Address:4 0.ck-k 1 1 ut i. , Fireplace, factory-built: wood gas
_.., a.0.4 a r'i i,.. , A> i c k'xa o • Fireplace,masonry: (w o gas
Furnace: wood gas oil
Phone: _ ; '? ' 6` ( - ;? `5 .
If non-masonary applicance, please provide
n�
Owner:Mi�z K9\ '- rt e . 50011 H A4Li 1,41 0,, „9 Manufacturer Name:.
Address: St-). t,J c.`>r o r2 Y A LIC. .Model Number:
- cAr•cA) t.SL•Atli t 14) ItO312 I
' Chimney Information
Phone:. -=)I g ` d -)3 l >cc (circle appropriate words)
Masonry block ' ri& . stone .
• Flue l?i TO steel size: A ° . inches
Exact Address: 30 61 x. 066 OR i` C
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 Queenshury ..
Handouts regarding required inspections. •Double wall / Triple wall / Insulated I Direct venting
• - Chimney Liner
•I Ca.,ahier'ass Depizrtment—Z'o .uof Queenuecbzzry, New 7E-ox-hr
lr
Fire Marshal-Code# $Collected _ $Re�ficrided Received from (refunded to): .f I ' `� .ilk ) r;�
,
- y, • address: _..._— ---'
•
A 173 3389 (190) Public Safety _) •
A 233 2655 (2 30)Minor Sales
DATE: \ \ ,:- ^1 _r1`- i l� tt: l ( ) �6 1 l'• �-JI' .
White(Applicant) / Green(Fire Marshal) / Yellow(Bldg. Dept.) / Pink&Goldenrod(Cashier's Dept.)