applications PRINCIPLE STRUCTURE Office Use Only
PERMIT APPLICATION �7,U�-�V
Permit#: �e. r J
Town of Quccnsbury Permit Fee:$ 55 1 + (0__(0
742 Bay Road,Queensbury, NY 12804 *Rec. Fee:$
P: 518-761-8256 www.queensburynet ��
Invoice#: 2-96-st
Project Location: a O "7K ►vo X R4, Let eft g• r/� 11.1 1 z 'a"—
Tax Map #: 2 39, "7, (, Subdivision Name:
TOWN BD.RESOLUTION 86-2013:$850 recreation fee for new dwelling units: single family, duplexes/two-family,
multiple family, apartments,condominiums, townhouses,and/or manufactured &modular homes,but not mobile
homes. This is in addition to the permit fee(s).
CONTACT INFORMATION:
• Applicant:
Name(s): rJ a Het rrt e 1 171 gry /-larri c
Mailing Address, C/S/Z: 2 0 l(ive X Pot- L (-z •Qo rg-e- A f' / Zg'/ s-
Cell Phone: (3 0 " ) Land Line: (S-i Fl ) ( S-G
Email: / /at-rIc� l' / - Roar ,/ it mer-> com
• Primary Owner(s): I 0
Name(s): 1r1 et y f-1 u rr1`s ('�- i1 to Q. �e /s A ;Z63 51-4. � Oak n r-
•MailingAddress, C/S/Z: O Knox (?Gl, L eowD Ale _
Cell Phone: (3 i1 s- ) 7-7e30! Land Line: ( 5"-t ) 6 S 6- y 5 5 S'
Email: V Hatri'S G Roo-Ire/ n kt e>~, eon Lt.a(5•A `/ boys e. va-400,c- k
❑ Check if all work will be performed by homeowner only
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): f(e vt'a /7) Ay n and Consf j--oc'?/-i v n
Contractor Trade: -w.ra/ Ca x' -p-o c fei;-
Mailing Address, C/S/Z: /0 3 7%' i't 1 y 9, R'nrl n•Y 12. ?
Cell Phone: (51 $ ) -3 4/S8 Land Line: ( )
Email: -/rerun (p If aotnMaynaro(c ')t5tp-vd;on Corn
**List all additional contractors on the back of this form
• Arch itect(s)/Engineer.(s):
Business Name: Ha r V- 5' )4 yvc
Contact Name(s): n e-l, H /`it- n ter
Mailing Address, C/S/Z: /33 / Cole R oe-c, lJ.e /cut S ail - / 20 53
Cell Phone: ( Si'i ) 4 5`7- 9 I o Land Line: (51$ ) Y95-- 7.3 4l
Email: de-I3 L. 11art. estAo,Lje5 , Com
Contact Person for Building & Code Compliance: T e oe-N v?)►
Cell Phone: Land Line:
Email:
Principle Structure Packet Revised February 2019
c a
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): B N vi c e 5 to v-e n S'o h �x t ez,-/'11 n$
Contractor Trade:
Mailing Address, C/S/Z: l; ( S to l e 11So it u1 Q y� Fir 1-14 i n, ,li 8 -7
Cell Phone: .( 5 19 ) LJo( - `74 5" 9 Land Line: ( )
Email:
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: ( ) Land. Line: ( ),
Email:
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: ( )
Email:
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s):_
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: ( )
Email:
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: .( )
Email:
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: ( )
Email:
Principle Structure Packet Revised February 2019
C 5
IIIPPROJECT INFORMATION:
TYPE: _Commercial PC Residential
WORK CLASS:
Single-Family Two-Family _Multi-Family(#of units )
Townhouse Business Office Retail Hotel/Motel
_Industrial/Warehouse _Garage(#ofcars ) _ Other(describe )
STRUCTURE SQUARE FOOTAGE: GARAGE SQUARE FOOTAGE:
1ST floor: ,j 7 1ST floor:
2"d floor: 2nd floor:
3rd floor:
Total square feet:
Basement(habitable space): 5 3
Total square feet: 113-4-
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$ !62. c°1 oe
2. Proposed use of the building:
3. If Commercial or Industrial, indicate the name of the business:
4. Source of Heat: 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 Explain:
6. Are there any easements on the property? YES I1 0
7. SITE INFORMATION:
a. What is the dimensions or acreage of the parcel? i 3 a_t 1-4-5
b. Is this a corner lot? YES NO
c. Will the grade be changed as a result of the construction? YES I�
d. What is the water source? PI IRI LC PRIVATE WELL
e. Is the parcel on SEWER or a RIVATE SEPTIC)system?
Principle Structure Packet Revised February 2019
r 5
DECLARATION:
I. lacknowledge that no construction shall commence prior to issuance of a valid building
permit and work will be completed within a 12 month period.
2. If the work is not completed by the 1 year 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 true 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 Uwe 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: 1-1 Harr S
SIGNATURE: 7P DATE: 911, 0
Principle Structure Packet Revised February 2019
I • 5.
i Office Use Only
; Permit#:
1 SEPTIC DISPOSAL PERMIT APPLICATION Permit Fee:$ ; Invoice#:
Septic Variance? Yes No
Town of Queensbury
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net
Tax Map ID#: 239.7-1-23
Project Location: 20 Knox Road -Assembly Point
• Applicant:
Name(s): John & Mary Virginia Harris
Mailing Address, C/S/Z: 20 Knox.Road, Lake George, NY 12845
Cell Phone: _( 315 ) 527-7585 Land Line: _(
Email: harrisj181@roadrunner.com
• Primary Owner(s):
Name(s): Same
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _(
Email:
❑ Check if all work will be performed by homeowner only
• Contractor: Workers' Comp documentation must be submitted with this application
Contact Name(s): Stevenson Excavating
Contractor Trade: Site work
Mailing Address, C/S/Z: 61 Stevenson Way, Fort Ann, NY 12827
Cell Phone: _( 518 ) 401-7659 Land Line: _(518 ) 743-0713
Email:
• Engineer(s):
Name(s): Hutchins Engineering
Mailing Address, C/S/Z: 169 Haviland Road, Queensbury, NY 12804
Cell Phone: _( ) Land Line: (518 ) 745-0307
Email: LWDobie@hutchinsengineering.com
Contact Person for Building & Code Compliance: Bruce Stevenson
Cell Phone: ( 518 ) 401-7659 Land Line: (
Email:
Septic Application Revised February 2019
• . A
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms: X gallons per =total daily flow
per day bedroom Garbage Grinder Yes No
1980 or older 150 Installed? (circle one) X
1981-1991 130 Spa or Hot Tub Yes No
Installed? (circle one) X
1992-Present 110 3 110 330
PARCEL INFORMATION:
Topography I Flat Rolling Steep Slope %Slope
Soil Nature ✓ Sand _Loam ✓ Clay Other(explain:
Groundwater At what depth? 48"
Bedrock/Impervious mate ' At what depth? > 80"
Domestic Water Suppl /j4K& _Municipal _Well (if well, water supply from any septic system absorption is ft.)
Percolation Test Rate: 12:00 per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size 1000 gallons (min. size 1,000 gallons, add 250 gallons for each garbage cylinder or spa/hot tub
System Absorption field with#2 stone Total length ft.; Each Trench ft.
Seepage Pit with#3 stone How many: ;Size:
Alternative System Bed or other type: 9' x 62' Bed
Holding Tank System Total required capacity? ; tank size ;#of tanks
NOTES: 1. Alarm system and associated electrical work must be inspected by a Town 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. 3. As-built drawings must be
submitted prior to the inspection, if there has been a change to the submitted plans.
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 the Town of Queensbury
Sanitary Sewage Disposal Ordinance.
PRINT NAME: IT d' 414 JJ' t t)'` f S DATE: O//6/'2o
•
SIGNATURE: 61- ?f4/1.1144 DATE: g/t r f
Septic Application Revised February 2019