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` PRINCIPLE STRUCTURE Office Use Only PERMIT APPLICATION Permit#: 0514 ' 2.(a2-0 Town ofQuccnsbury Permit Fee: $ `J J (DQfic2 F/ 742 BayRoad,Queensbury, NY 12804 ®�� *Rec. Fee: $ 65G P: 518-761-8256 www.queensbury.net �1 Invoice#: Project Location: 7 G //ie , a Ort.r. Tax Map #: / , /O- ) - 143 Subdivision Name: TOWN BD.RESOLUTION 86-2013:$850 recreation fee for new dwelling units: single famil , du e s/two-family, multiplefamily, apartments,condominiums, townhouses,and/or ma rrfaccjl rf qLE b t not mobile homes. This is in addition to the permit fee(s). D CONTACT INFORMATION: R sEp ' 2020 • Applicant: 1 { TOWN OF OUEsE-NSBURY Name(s): �C'f'� c_ A tJ i L�P P OVEBUILDING&CODE.-S Mailing Address, C/S/Z: 15 eel 1) roo 6 9 Cell Phone: ( 51F ) �72.i-7 /77 Land Line: ( Email: �, c4✓1HI. � C eiro.2e- bca1` 6� � • Primary Owner(s): Name(s): o.S a1c•N ) Mailing Address, C/S/Z: Cell Phone: ( ) Land Line: ( _) Email: ❑ Check if all work will be performed by property owner only • Contractor(s): Workers' Comp documentation must be submitted with this application Contractor Name(s): c as o a),1U Contractor Trade: Mailing Address, C/S/Z: Cell Phone: ( ) Land Line: ( ) Email: **List all additional contractors on the back of this form • Architect(s)/Engle eer(s): Business Name: <�1 U k cob; e rn,7 Contact Name(s): 0 can Rc,`f(✓► Mailing Address, C/S/Z: 90 (5 t 7(n Cell Phone: ( ) Land Line: ( S Itt ) ^7 ea - %' Y Email: Contact Person for Building & Code Compliance: 64I Gr lM i S / ✓►' o, e Cell Phone: ( ( Q�j)7 Z q_ r71/77 Land Line: (.( ) -7Z'3 -7N77 Email: i s h I C err'€M,e cb`Mrs (o Revised January 2020 PROJECT INFORMATION: TYPE: _Commercial residential WORK CLASS: Single-Family Two-Family Multi-Family(#of units ) Townhouse _Business Office Retail Hotel/Motel _Industrial/Warehouse Garage(#of cars ) _ Other (describe ) STRUCTURE SQUARE FOOTAGE: GARAGE SQUARE FOOTAGE: 1ST floor: IqL 1ST floor: t1O c) 2nd floor: 2nd floor: 3rd floor: go Z Total square feet: Basement(habitable space): Total square feet: 15 ('L ADDITIONAL PROJECT INFORMATION: 1. Estimated Cost of Construction: $ g)fOOD 2. Proposed use of the building: l & rrvl 3. If Commercial or Industrial, indicate the name of the business: 4. Source of Heat: Gas Oil Propane Solar Other: G-, (Fireplaces need a separate Fuel Burning Appliances&Chimney Application, one per appliance) 5. Are there any structures not shown on the plot plan? YES ONO Explain: 6. Are there any easements on the property? YES GO 7. SITE INFORMATION: a. What is the dimensions or acreage of the parcel? b. Is this a corner lot? YES c. Will the grade be changed as a resu of the construction? YES N d. What is the water source? 'UB PRIVATE WELL e. Is the parcel on SEWER or a PRIV A SEPTIC system? 1204C Prinrinle Stnirtura Parkat Raviced lanuary 7n7n DECLARATION: I. I acknowledge that no construction shall commence priorto 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 approva I. 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 li4ve are required to provide an as-built survey by a licensed land surveyor of all newly constructed facilities priorto issuance of a certificate of occupancy. I have read and agree to the above: PRINT NAME: SIGNATURE: DATE: ` '$ -10 Ro,,.,o,l in.,,in.,,7r7n NATURAL LIGHT,VENTILATION&EMERGENCY EGRESS CALCULATION SHEET Project Location: L 4(,tie4 ,1 rl i& 1f Ii- II Primary Owner (s): Ce cn le kU i 1(1-fr) Habitable Sq. Ft. Required Actual Required Actual Sq. ft. Rooms of Light Light Ventilation Ventilation opening Room (8% of rm.) (sq. ft.) (4% of room) (sq. ft.) for Egress (14 - 41.-7 C'tq 103 (0 27( s 01 2- rlu afr) {ct1 (6 , 3 v- 1 777 io• / `3C U ( la© I d• '1 22-4 � Z 1,0. `f ►—, ) PA Z(o ‹o )C Z-1 el(23G IJA 3fD 3tt I, c 1• (Q OLD, IA/ 1 Iii c-t. 3 10, Y o.i......le cf....t...e.oseLer Q ..mrl Cnhrnon.9mo Office Use Only FUEL BURNING APPLIANCE & Permit#: C. S[4 v t �, .f:) { CHIMNEY APPLICATION Permit Fee:$ :_> - Invoice#: 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.queensburynet Project Location: ZL 1-.'� O'uv? Tax Map ID: Z 1 S . /© - 1 — 4/3 Room of Install: L 3 Planned Install Date: oc,f. **ONE APPLICATI ON PER APPLIANCE** CONTACT INFORMATION: • Applicant: Name(s): Ces'I'o ix I)-( c\-er . Mailing Address, C/S/Z: / 5 F7 1 a, k ci /Z7Z7 Cell Ph.: _++ ( ‹t6 ) -71,c/ - 7y77_ Land Line: _( $ ) y - Email: (...i�l,e0141✓lir �i C e-rPo•te t)u,tcLi*- cr 1M • Primary Owner(s): Name(s): Mailing Address, C/S/Z: Cell Ph.: _( ) Land Line: _( ) Email: ❑ Check if all work will be performed by homeowner only • Installer/Builder: Workers' Comp documentation must be submitted with this application ,f Contact Name(s): ) e ere Contractor Trade: r'r,e, sa/ace - Mailing Address, C/S/Z: Cell Phone: _( S.T'4 ) — Land Line: _( ) Email: Contact Person for Building & Code Compliance: 2.7/''ef vv, cS /?u,14 Cell Ph.: _( S',' ') 7 Z q-7y7 7 Land Line: _( ) Email: 6"---v ,„, ,, H. " l tad e-, cdiii Principle Structure Packet Revised January 2020 FUEL BURNING APPLIANCE INFORMATION: TYPE OF DEVICE: _Stove >crireplace Insert _ Fireplace Fuel Fired Equipment (Garage Only, 18" clearance per IMC 304.3) Fireplace, factory built** gat,i (**Manufacturer's name: - (, /f 0 Model #: V 3 7-71 SOURCE OF HEAT: Wood _Coal Pellet X- Gas CHIMNEY INFORMATION: Masonry (require plans to be submitted): block brick stone X'Flue: tile _steel size, in inches Material*: double-wall _triple-wall insulated (*Manufacturer's name: ( ex— 0Y04'" Model#: ADDITIONAL INFORMATION: 1. Two inspections are required. A rough-in inspection, 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 inspections. 5. Workers' Comp insurance information is required with this application. Declaration:Construction/installation must conform to NYS Fire Prevention & Building Code and/or manufacturer requirements. 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 the inspector to enter the premises to perform the required inspections. I have read and agree to the above: PRINT NAME: 6/0/i r � /vrJ SIGNATURE: DATE: ` -F'2-c) Principle Structure Packet Revised January 2020 .4 I Office Use Only To n of(been sbury SEPTIC DISPOSAL PERMIT APPLICATION Permit#: Permit Fee:$ ; Invoice#: Septic Variance? Yes No 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.aueensbury.net Tax Map ID#: SiS 10 " � (43 Project Location: ZC). ON Lie • Applicant: Name(s): ctol u(`k L Mailing Address, C/S/Z: 1c�� 12,(D J-�c °1 Ft a�,-,icy-d /I /7 )-4 Cell Phone:_( �1� 11 c1-7q-7 Land Line: _( Email: ignw, L, CC.rr? e 60- 1 • C6M • Primary Owner(s): Name(s): Mailing Address, C/S/Z: Cell Phone: _( )_ Land Line: _( Email: El Check if all work will be performed by homeowner only • Contractor: Workers' Comp documentation must be submitted with this application Contact Name(s): Frc- Contractor Trade: Mailing Address, C/S/Z: Cell Phone:_(5/ ) 7a(-l- c-6 Land Line: _( Email: • Engineer(s): Name(s): Mailing Address, C/S/Z: Cell Phone: ( ) Land Line: _( Email: Contact Person for Building & Code Compliance: G ,ur(t, ,r/tv, Cell Phone: (,6-/i ) `7 Zq- 71177 Land Line: ( ) Email: a,i✓i/ ,® L;er/Z/Le it ._ co Principle Structure Packet Revised January 2020 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) Spa or Hot Tub Yes Co) 1981-1991 130 Installed? (circle one) 1992-Present 110 3 10 3 O PARCEL INFORMATION: Topography X. Flat Rolling Steep Slope %Slope Soil Nature 's`Sand Loam _Clay _Other(explain: Groundwater At what depth? Bedrock/Impervious material At what depth? Domestic Water Supply '?(Municipal _Well (if well,water supply from any septic system absorption is ft.) Percolation Test Rate: per minute per inch (test to be completed by licensed engineer/architect) PROPOSED SYSTEM FOR NEW CONSTRUCTION: Tank size /Ow, 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 /62, - ft.; Each Trench_ Ss° ft. Seepage Pit with#3 stone How many: . ;Size: Alternative System Bed or other type: 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: t ( S( ao.2G DATE: ?-8 Z SIGNATURE: DATE: ?"' 8P- -lc) Principle Structure Packet Revised January 2020