applications Office Use Only
Permit#: QC
•
PRINCIPLE STRUCTURE PERMIT
APPLICATION Otti! Permit Fee:$ `�21Q too
icunct
742 Bay Road Queensbury, NV 12804 *Rec.Fee:$ TAIA-
P 518-761-8256 a,:;. invoice#: 1)5n
Project Location: c+ SOH N C I-CN>b1P Ro
L T
Tax Map #: 21 , 15. 2— 11 Subdivision Name: I-6 N N C.L.GPOou R t
TOWN BD.RESOLUTION 86-2013.$850 recreation fee for new dwelling units single family,duplexes,two-family,
multiplefamily, apartments,condominiums townhouses,and or manufactured & modular homes but not mobile
homes. This is in addition to the permit fee(s).
CONTACT INFORMATION:
* Applicant: j l
Name(s): '�t� T(-Ii LLS u t t_sD E k-S l.TO E LEu c-t
Mailing Address, CISIZ: 1 m o u>d TR t t3 S to 1J R►VE Que-_'s& P4 t '1 12fo
Cell Ph.: f ( St S ) t t 33 Land Lino: i (St ) 1U2-3s-Zo (Cd- -)
Email: Foo titLt-SBu.t L-Dl✓Rs Ny' g C—mflt1_. c-oflorN
• Primary Owner(s):
Name(s): Sp cnY AS A PPL t C.flr4-r
Mailing Address, CISIZ: ^�
Cell Ph.: ( ) Land Line: E '
Email:
i 7 N 20 2018 11.9
• Contractor(s): TOWN OF QUEENSSURY
Name(s): S i im AS A P tp L c r N-C Bu!LnING R r:[ rws
Mailing Address, CISIZ:
Cell Ph.: ( ) Land Line: ( )
Email:
• Architect(s)IEngineer(s):
Name(s): i tU PE LV IS I o f E 14G-1 mo t:R t1,1 C
Mailing Address, CISIZ: 2-0 o O-i.. 5 i S uTe' 540 Grt-1as SAL-LS r'- f r 2-8-e 1
Cell Ph.: ( ) Land Line: i (5't ? ) -191 - 9 24y
Email: ijlZ.1 APO VtstotENG-. +v(YlijL
Contact Person for Building & Code Compliance: -SIDE LCtk c.l
Cell Ph.: I (S-t1 ) 11 1- ('133 band Line: i (st I ) 19 o 3S2C) (.LE`t-)
Email: Eoo t- stet-5 6(A. Li) P.-s , /@ 6 po ,co rv\
Tan Building&rode Fnfarrpmpnt Principle Structure Revkpri March 1011i
PROJECT INFORMATION: •
TYPE: Commercial X. Residential
WORK CLASS:
Dic Single-Family Two-Family Multi-Family(*of )
Townhouse Business Office Retail Hotel/Motel
`Industrial/Warehouse Garage(#ofcars ) Other(describe 3
STRUCTURE SQUARE FOOTAGE: GARAGE SQUARE FOOTAGE:
15Tfloor: /`/ 2 2-- c Z FS
2nd floor: 2nd floor:
3rdfl°or' Total square feet: C?
Basement(habitable space):
Total square feet: 2,-2--
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$ / S—® , 0
2. Proposed use of the building: I JS ID CNT e A
3. If Commercial or Industrial,indicate the name of the business:_
4. Source of Heat(circle one): Gas Oil Propane Solar Other:
(Fireplaces need a separate Fuel Burning Appliances&Chimney Application,one per appliance)
5. Are there any structures not shown on the plot plan? YES 0 plain:
6. Are there any easements on the property? YES ►0
7. SITE INFORMATION:
a.What is the dimensions or acreage -)parcel? O 661 A e'12-t'S
b.Is this a corner lot? YES
c.Will the grade be changed as a res e construction? YES NO'
d.What is the water source? `UBLIC 1 PRIVATE WELL
e.Is the parcel on SEWER or a PRIVATE SEPTIC system? P l'd T C
Ton Ruiidin2&tocip Fnfnrcemant Prinrtnio Ctnlrt/ira RcVkPfi Niarrh?frig
DECLARATION:
I. I acknowledge that no construction shall commence prior to issuance of a valid building
perm and work will be completed within a 12 month period.
2. If the work is not completed by the 1year expiration date the permit may be renewed,
subject to fees and department approval.
3. I certify that the application, plans and supporting materials are a t rue 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. I acknowledge that prior to occupying the facilities proposed I, or my agents, will obtain a
certificate of occupancy.
5. I understand that l/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: In EP 1{ LEU
SIGNATURE: b DATE: Co fliehR
•
•
TaQ Building&Code Enforcement orinrint.SPntrt,Irn Ravimri Marrh 7ffiR
Office Use Only
FUEL BURNING APPLIANCE & Permit#:
CHIMNEY APPLICATION
Permit Fee:$
Invoice#:
742 Bay Road, Queensbur y, NY 12804 P:
518-761-8256 :.r ,, .,_ , , , _Mt
Project Location: C l Jc HiJ CL -Pm- Tax Map ID:
Room of Install: 0-9--EA1' Planned Install Date: g /i (IF
**ONE APPLICATI ON PER APPLIANCE`*
CONTACT INFORMATION:
a Applicant:
Name(s): F-o o i H t i-us '0 Lk 11._ E Qs Ltrt (a 0 6 LEu c- i)
Mailing Address, C/SIZ: IDE >sL Que ,NSgoR--1 N y I/So y
Cell Ph.: I (Sig ) 1'9 1` I`j 3 3 Land Line: ( ( S t g ) -35-20 (ccu)
Email:_ GM i 61kl i. 1)cizs e c-IT\fI 1 z- C 6 M
• Primary Owner(s):
Name(s): c'ArnE- f3 flf'Pi-i . A ,0-1'
Mailing Address, C/S/Z:
Cell Ph.: ( ) Land Line: ( ) _
Email:
• Installer/Builder:
Name(s): S R rn e 1 ape
Mailing Address, C/S/Z:
Cell Ph.: ( ) Land Line: ( ) -
Email:
Contact Person for Building & Code Compliance: J% i' LEI" I
Cell Ph.: 1 (s—I? ) 1°1 I - 1.133 Land Line: ,L( c1 if ) 1 6 - 3S-2 o CceLL
Email: r, e4-1 • Fo r ILL{130-1 L-D e s Ai ye G-m f11 L,• rma
Tu.vn of Queensbuy Buldry&Code Enforcement
FUEL BURNING APPLIANCE INFORMATION:
TYPE OF DEVICE:
Stove X Fireplace Insert ,Fireplace
iHITE` mokr�Ti�rN lhcbFL Dv TANo6 ��LuX�
�
_Fuel Fired Equipment(Garage Only, B"clearance per IMC 3043)
Fireplace,factory built**
**Manufacturer's Name: Model#:
SOURCE OF HEAT: •
Wood Coal Pellet Gas
CHIMNEY INFORMATION:
_Masonry:
block brick stone
Flue:
tie ( stJ 12,size,ri inches
Material*:
double-wall i triple-wa Il_insulated
(*Manufacturer's r t r-rn e: Model#:
ADDITIONAL INFORMATION:
1 Two inspections are required. A rough-in hspection,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 hspections.
peclaration:Construction/installation must conform to NYS Fire Prevention&Building Code andlor manufacturer
requirements,The applicant or owner agrees to comply with all applicable bws,ordinances,regulations and all
conditions that are part ofthese 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: OSEP H LE" C-1 —
. .
SIGNATURE: �` / � _ L7ATE:, ‘ 1 l rI 1 g
Fuel Burning Appliance Chimney Application
9.
( .
;j SEPTIC DISPOSAL PERMIT APPLICA T I ON • Office Use Oni
'' = 742 Bay Road.Queensbury,\V 12DO4
P 518-76 -N'56 Permt;:
Tax Map ID#: Permit t ee S !:u .DP r: F=
Project Location: c I J5 Rh-) C C D6 N el) - e : .&l nne? - _NI--)
Primary Owner(s) 1 To 0 T I-I Z-LS AU-i/...be LC `,s LJ0c LEA (-1)
Mailing Address 1 /Yl6LA.NTAwsfoe t1. QuePNs8LtP-i 1''1"/ 12go11
Phone& Email ICS-t$)I`ll-ii33 l (S(019(9'352 FooTHILt-SPut{LDegsiosi esermAIL,60
Installer/Builder SD,.me- As A9PC-TCANT
Mailing Address
Phone& Email
IEngineer o rh ezyu`Er R e.c,
Mailing Address 1(a5 WWI C-A ni r' RD Q,u. e NS 8 vi(L`-1 RJ i t 2S 01
Phone& Email CS I 01°1(a-zSi .5 T NT15-R3& QYANoo. C.oM
Contact Person for Building&Code s Dmpiir at :ce: ae- T"Bv_L( P!"Icsn : t. ) )191 " (933
(Sit) 1 '-3.s-2-0
RESIDENCE NFORMATION:
Year Built #of bedrooms X gallons per bedroom = totaldaily flow Garbage Grinder Yes No
1380 or older Installed? {circle one)
1981-1 91 --'"'- Spa or Hot Tub Yes No
Installed? {circle one)
D92-Pr`aserit 3 (® 33 U � .. »_ ._
PARCEL NFORMATION:
Topography '' V—P - Flat Rolling Steep Slope %Slope
Soil Nature i k,Sand _ Loam Clay _,Other
Groundwater M At what depth? i✓j q
Bedrock/lmpervbusmaterial I At what depth? r✓(A
Domestic Water Supply IX_Municipal ,_Well{if well,water supply from any septic system absorption is ft.)
Percolation Test I Rate: II -6- per minute per inch(test to be completed by licensed engneer/arcltect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size to U 0 gallons{min-size 1000 gallons,add 250 ga lions for each garbage cylinder or spa/hot tub
System Absorption field with#2 stone Total length 1 TO ft.;EachTrench $"b ft.
Seepage Pitwith#3 stone "How many: -Size:
Alternative System Bed or other type: _
HoldingTank System Total required capacity? -tank size :# of tanks
NOTES:'Alarm system&associated electrica iworkmust be inspected by aTow n approved electrical inspection
agency;2.We will no longer allow systems to be covered until such time as an as-built plan is received and approved.
The installed system must match the septic layout on file-no exceptions.
Declaration:Any permit or approval granted which is based upon or is granted in reliance upon any material
representation or failure to make a material fact or circumstance known by or on behalf of an applicant,shall be void.i
have read the regulations and agree to abide by these and all requirements of theTown of Queensbury Sanitary Sewage
Disposal Ordinance. r
PRINT NAME: ) (,0 S C P A EL( C DATE: ( /1 ld
lj �l�
SIGNATURE: DATE:
Town of Oueensbury EJ.+d.n;&Code Enforcement Re,:-..,-,EebYu'j 208
C
'
Town of Queensbury Thomas R.Van Ness
Highway Department Highway Superintendent
742 Bay Road,Queensbury,NY 12804 Home:518-745-0929
Phone:518-761-8211
Fax:518-745-4466 David Duel!
Deputy Highway Superintendent
Home:518-745-0938
DRIVEWAY PERMIT
Date: (p
Applicant Name: Foo T HtLLS BLA-I(.DO(ZS (.70 Le-ut-(/
Telephone No.: (Sig)-79 1- (q 33 /(f 1 if)-%-352_D
Address to be Inspected: c l To ft N C 0 6 P R>
Return Address: mo u^'-rA i N S tD E 1�
QIne'ENSp,(Alz1 t l2Z$b'�
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 approval permit for a final approval.
STEP 2: ( ) Final Approval ( ) Rejected
Date:
Thomas R.Van Ness, Highway Superintendent David Duell, Deputy Highway Superintendent
Town of Queensbury Building&Code Enforcement Principal Structure Application Revised February 2017