applications Office Use Only
l✓ G
"7 J T Permit#: ; ,g6 't v/
, PRINCIPLE STRUCTURE PERMIT ,
APPLICATION Permit Fee:$ ^�4,17 00 t l 7.s `� 4 .4,1(
ef
*Rec. Fee:$ �j'7�
742 Bay Road,Queensbury, NV 12804
P: 518-761-8256 Invoice#: ����
Project Location: C"✓-1-rkvI euJ Oven e
Tax Map #: 3 o),. / / •--3 -- Lf 7 Subdivision Name:
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:
Name(s): ,eo6e (arn"Icr1 (6 ,ii -i Ceram -u41-7,,--► L L<-
Mailing Address, C/S/Z: 3o C /-'ry►e,i 4ueric < znz4 j , 5/or:>, .4' / /?N 6 A
Cell Ph.: ( 5i e ) 3 r76 - 8 3C;2 it, Land Line: —( S,' ) 8,7-9t•s Y
Email: Rob 0 b06 6:file/s J )Scs r (-0/V 7
• Primary Owner(s):
Name(s): 4r� r be I- r- �ryin/1 ( C'-*n-prr0, (.,..,►1s/a 1 j-10c LLC )
Mailing Address, C/S/Z: 3 0 Cie rneri-i- t ric,c Si,, 499 . Ce,e.,,, •U \ 0 A £ 6
Cell Ph.: _( 5/f; ) 376 P,3 k Land Line: ( s/S ) - 33"7 - 3 y 3
Email: 404 & h:- ,4c,/'/ch &x.)SeS n c ,vl
• Contractor(s):
Name(s): C .,,,1n,o,-, �F;n sI-o4<17cy1 LL C;
Mailing Address, C/S/Z: 30 C/erti"/— a4.4.4a e _, -,cc,/,3G r-,•� S' /V /t)i 6 6
Cell Ph.: ( SI S ) sr)6 8 .3 C Land Line: _(SI ti ) ,. g�- 3y 3
Email: Tub &J b04bc41-/cdShooScS- C''
• Architect(s /Engineer(s):
Name(s): ' lh€,n Ned/ ( lai c i,7 5 k i - I--//*// a-c l/le c re
Mailing Address, C/S/Z: / 3 / I), X A tie nw
Cell Ph.: _( Si ) Land Line: (;;/b ) 71// - 0,>16 8
Email: a /'Act// ij, /y
car rr- coivi
Contact Person for Building & Code Compliance: 80 6 gcicr»o n
Cell Ph.: ( Si e ) 3'7 6 03 ) 6 Land Line: ( .- - --
Email: dc' fob6ui'/dshwss •- c
ToQ Building&Code Enforcement Principle Structure Revised March 2018
•
PROJECT INFORMATION:
TYPE: Commercial Residential
WORK CLASS:
Single-Family Two-Family Multi-Family(#of )
Townhouse Business Office Retail Hotel/Motel
Industrial/Warehouse Garage(#ofcars ) Other(describe )
STRUCTURE SQUARE FOOTAGE: GARAGE SQUARE FOOTAGE:
1ST floor: / J 93, 1ST floor: 'y 98
2"d floor: '✓/A- 2nd floor:
3rd floor: A✓/4
Total square feet: 1tYe
Basement(habitable space): N/A-
Total square feet: /
ADDITIONAL PROJECT INFORMATION:
�/�'
1. Estimated Cost of Construction: $ ! a( p2 am—
d
2. Proposed use of the building: „ /� 2. 1//y /?e , /t ie_
3. If Commercial or Industrial, indicate the name of the business: /41`4-
4. Source of Heat (circle one): was 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 NO xplain:
6. Are there any easements on the property? YES
7. SITE INFORMATION: �--�
a. What is the dimensions or acreage o�parcel? 56 F'/ K /6('
b. Is this a corner lot? YES
c. Will the grade be changed as a result of the construction? YES NO
d. What is the water source? P :LIC PRIVATE WELL
e. Is the parcel on SEWER or alp RIVATE SEPTIC_Srstem? /r, ti a Sc p ft
ToQ Building&Code Enforcement Principle Structure Revised March 2018
• 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 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 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 I/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: I , 'r-F ni o •�1
SIGNATURE: /�0 DATE: 't 31- at
ToQ Building&Code Enforcement Principle Structure Revised March 2018
Office Use Only
FUEL BURNING APPLIANCE & Permit#: - '�
CHIMNEY APPLICATION
Permit Fee: $ / S
Invoice#: /60
of Queensbu
742 Bay Road, Queensbury, NY 12804 P:
518-761-8256 www.qua..>; s': . ry.net
Project Location: Pqr k&teu) O .t'n LI(. Tax Map ID: 3 O, 4 / 3 -- 417
Room of Install: 1 ivir/ Planned Install Date: °T61)
**ONE APPLICATI ON PER APPLIANCE**
CONTACT INFORMATION:
• Applicant:
Name(s): l�ohtr
Mailing Address, C/S/Z: 3L) Cieim i / f)jje,ie ra S *•ity-5 /-)
Cell Ph.: (5/f3 ) S9(0 Land Line: _(S/3 ) ,) 0 r7-93 y3
Email: ,C le)xed kishY)se s �c'-
• Primary Owner(s):
Name(s): gc.)6r I C' Ord, ( rn loe„ LLC
Mailing Address, C/S/Z: / 5 /4.6 --
Cell Ph.: ( ) Land . e: ( )
Email:
• Installer/Builder:
Name(s): jb/,se(1- C,7•1too C1-4,Aie_i.o?-r Li C
Mailing Address, C/S/Z: 5 jJ e( .�
Cell Ph.: ( ) Land Line: ( )
Email:
Contact Person for Building & Code Compliance: ?ober I 6 P77,11
Cell Ph.: S/ �7 ( Land Line: ( )
Email: ,/ S wseS LaJ 1
Town of Queensbury Building&Code Enforcement
FUEL BURNING APPLIANCE INFORMATION:
TYPE OF DEVICE:
Stove Fireplace Insert / . Fireplace
Fuel Fired Equipment(Garage Only,'B"clearance per IMC 304.3)
J Fireplace, factory built**
** Manufacturer's Name: //, k (1?-/n Model#: 1-1(;SL 7
SOURCE OF HEAT:
Wood Coal Pellet
CHIMNEY INFORMATION:
Masonry:
block brick stone
Flue:
tie steel size in inches
Material*:
double-wall triple-wa II_insulated
(*Manufacturer's Model#:
ADDITIONAL INFORMATION:
1. Two inspections are required. A rough-in inspection,prbr 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.
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 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: RO4 ear i-,71/norl ( MM I1-2.1,c ) —
SIGNATURE : L /_,; - f -rµ--�-�� (i�l�rn�,-,-� DATE:NI I / Lt1�9
Fuel Burning Appliance&Chimney Application
a
4' ,, SEPTIC DISPOSAL PERMIT APPLICATI ON Office Use Onl
?42 Bay Road,Queensbury NY 12804
P:518-761-8256 w der l aens� r,, , Permt##:Q.L -L1�''E�--10le--t to - Z
Tax Map ID#: 36�6 i 1 _'3— •7 u 7 Permit Fee:$ -Invoice#:
Project Location: �O Septic Va
riance? Yes - N o
/Primary Owner(s) b c4- Ge m rn on (4-iii-rvi m O \ (..OyS+-ruction LLC )
Mailing Address 30 ((emNnct- tiro,t. lecci cS { . I Vo(o
Phone& Email Spii(510V2(0—e-sa (c ko3bc Lids hoisc s , corn
Installer/Builder C--A}nni'v)(D►i roil -t(u(-40A LL.L •
Mailing Address Se-c A ‘C L.,R__
Phone & Email e, 2. ►v bo`,-
Engineer E i'rtGrn p /"M- 1/
Mailing Address J3 Li D x ikenue_ Cierts , T Ms hi•�` ids got
Phone& Email ' i ) wi-�j 6 e phc I/Q /) yCQ(( rr- corn
Contact Person for Building&Code Comp[iarzc�: / Phori :
RESIDENCE NFORMATION:
Year Built #of bedrooms X gallons per bedroom = totaldaily flow Garbage Grinder Yes !4lo,
1380 or older Installed? {circle one)
1981-�91 Spa or Hot Tub YesNoo
Installed? {circle one)
' 1992-Present Z /HO 330
0
PARCEL NFORMATION:
Topography I((FlatrRolling Steep Slope %Slope
Soil Nature Sand _Loam Clay _Other
Groundwater A!C At what depth? /lam .'
Bedrock/Imperviousmaterial At what depth? r/ /I-
Domestic Water Supply AA, . Municipal _Well {if well,wate r supply from any septic system absorption is_ft.)
Percolation Test Rate: per minute per inch{test to be completed by licensed engneer/arcItect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size gallons{min.size 1,000 ga llons,add 250 ga lions 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: r
Alternative System Bed or other type: 6'Lj c n /5 r1
Holding Tank System Total required capacity?. -tank size ;# of tanks
NOTES:1.Alarm system&associated electrica lwork 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.
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: 601)4' M 01`0el 641$111rcvl Cf;1151- ec114,�14) DATE: /di 31 z-u I A
5,7
`` tt SOC
SIGNATURE: C?�tz�C i�-t �'"�.'� ) DATE:11-1-11-1444
Town of Queensbury Building&Code Enforcement Revsed February 2017
Town of Qu -scury Thomas R.Van Ness
Highway Department Highway Superintendent
742 Bay Road,Queensbury, NY 12804 Home: 518-745-0929
Phone:518-751-8211
Fax:518-745-4466 David Duell
Deputy Highway Superintendent
Home: 518-745-0938
DRIVEWAY PERMIT
Date: n (( iry,oc
/�
Applicant Name: eC)13-e t+ C�ran�Mv\ I Or)4f(1 cl7o1N)
Telephone No.: @' )
Address to be Inspected: Pki i>;'-4 QUe (a ,idi/ 3 i 7 1
Return Address: 3 0 Cleme n-i- Q x'n(4 -e
.Sqr i-c c{ Sprint 5. .ti) oe oG
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