applications PRINCIPLE STRUCTURE Office Use Only
PERMIT APPLICATION
Permit#:
Permit Fee:$
742 Bay Road,Queensbury, NY 12804 *Rec. Fee:
P: 5 18-761-8256 Invoice#: 52-2-%,Q
Project Location: _414 -
Tax Map #: 30211 LL Subdivision Name:
TOWN BD.RESOLUTION 86-2013:$850 recreation fee for new dwelling units: single family, duplexes/two-family,
multiplefamily, apartments,condominiums, town houses,and/or manufactured & modular homes,but not mobile
homes. This is in addition to the permit fee(s).
CONTACT INFORMATION:
• Applicant:
Name(s):
E,
Mailing Address, C/S/Z:......I I
Cell Phone:_L JjL& J V;!J_ 17 1 2i Land Line: _f
Email:_ DUIX Cto rA
• Primary Owner(s):
Name(s): 'Sr
Mailing Address, C/S/Z:
Cell Phone: --Land Line:
Email:
e am J;qefV\ A+br-kd �-
El Check if all work will be performed by homeowner only
• Contracto'r(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): Y1S -\Aff ErlktY V'k VA
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: -Land Line:
Email:
"List all additional contractors on the back of this form L[�
• Arch itect(s)/Eng ineer(s): DEC 0 7 2020
Business Name: F
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
Contact Person for Building& Code Compliance: Day D
— -1d A16jiVg
Cell Phone: (51P) Land Line:
Email: daue cc cztaz2�- ct.,-,12n
Principle Structure Packet Revised February 2019
4
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s):
Contractor Trade: —RCcD �
Mailing Address, C/S/Z:
Cell Phone:�_) Land Line:
Email:
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): 4 %tAv AIO S lt�y r�u
Contractor Trade: q- e9b( . 2xlekVe-k-t-tV
Ij
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
PROJECT INFORMATION:
TYPE: _Commercial �, 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:
I'floor: 1703 11 floor: .577L
2"d floor: 0 2"d floor: CD
31 floor: C'O Total square feet: 5 7b
Basement(habitable space): CD
Total square feet: I'7013
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ 350,C=
2. Proposed use of the building: J !!:)&e_
3. If Commercial or Industrial, indicate the name of the business:
4. Source of Heat(na � 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 I) Explain:
6. Are there any easements on the property? YES
7. SITE INFORMATION:
a. What is the dimensions or acreage of the parcel? hr73C I
b. Is this a corner lot? YES g)
c. Will the grade be changed as a result of the construction? YES NO
d. What is the water source? UBLI PRIVATE WELL
e. Is the parcel on SEWER or a PRIVATE SEPTIC system? 6z2 `L_
Principle Structure Packet Revised February 2019
DECLARATION:
I. 1 acknowledge that no construction shall commence priorto issuance of a valid building
permit and work will be completed with in 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. 1 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. 1 acknowledge that prior to occupying the facilities proposed I, or my agents, will obtain a
certificate of occupancy.
5. 1 understand that Me are required to provide an as-builtsurvey by a licensed land surveyor of
all newly constructed facilities priorto issuance of certificate of occupancy.
I have read and agree to the above:
PRINT NAME: rt��r� on �Ur
SIGNATURE: DATE: /.a hht-�'
Principle Structure Packet Revised February 2019
Office Use Only
FUEL BURNING APPLIANCE & Permit#: P-c' D5- ZoZ�
CHIMNEY APPLICATION
i
Permit Fee:$
Invoice#:
742 Bay Road,Queensbury,NY 12804
P:518-761 8256
Project Location: Tax Map ID: .
Room of Install: Planned Install Date: ADYJ I �na-
**ONE APPLICATION PER APPLIANCE**
CONTACT INFORMATION:
• Applicant:
Name(s): NVA'VD R 1ZrJt I C
Mailing Address, C/S/Z: Ll 1 1Zeoe VP Q I` CPA)bU V 4 t l y I aW Y
Cell Ph.: _(5/b ) L!b I I.-)1 -3 Land Line:
Email: C6 oc r--1 L-0c, . co M
• Primary Owner(s):
Name(s): I,rxVV �� �►,r
Mailing Address, C/S/Z:
Cell Ph.: _(� Land Line:
Email:
❑ Check if all work will be performed by homeowner only
• Installer/Builder: Workers' Comp documentatio st be submitted with this application
Contact Name(s): w t S�wv-eJ
Contractor Trade:
Mailing Address, C/S/Z: Ll Of I
Cell Phone:_(
Email:
Contact Person for Building & Code Compliance: J-h� IV')UL
Cell Ph.: _(61 E) l b 1 )?) Land Line:_U
Email: guy- Ci GneT F [r)e'1
Principle Structure Packet Revised February 2019
FUEL BURNING APPLIANCE INFORMATION:
TYPE OF DEVICE:
_Stove Fireplace Insert _Fireplace
_ Fuel Fired Equipment (Garage Only, 18" clearance per IMC 304.3)
_Fireplace,factory built**(**Manufacturer's name: i A06 - o Model#: 6 L-7 )
SOURCE OF HEAT:
_Wood _Coal _ Pellet Gas
CHIMNEY INFORMATION:
_Masonry(require plans to be submitted):
block brick stone
_ Flue:
tile _steel —size, in inches
} Material
* double-wall _triple-wall _insulated
(*Manufacturer's name:' 1-lCed 4-610 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: L17id /7A 'Zi/U
SIGNATURE: 40o y ftba, DATE:
Principle Structure Packet Revised February 2019
f -
1
I
Office Use Only
SEPTIC DISPOSAL PERMIT APPLICATION Permit#: Pic Wz_0
Permit Fee:$ ; Invoice#:
Septic Variance? Yes No
742 Bay Road,Queensbury,NY 12804
P:528-761-8256 www.gueensbury.net
Tax Map ID#: 315P!_ 14- J—a6
Project Location:
• Applicant:
Name(s): I QA'Nr7)UV } ��p � ( ( C
Mailing Address, C/S/Z:
Cell Phone:_( 519-) ) L/h I- 1'7►IS Land Line: _( )
Email: 1--b1_ir° el C-A'jc. 1= cory\
• Primary Owner(s):
Name(s): Sc,"e ce, 4brxrr
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): ):.PtI&IVh 1 l x ra0A+; �
Contractor Trade: F is C ciI Vy+,my
Mailing Address, C/S/Z: link-AL. 64- )-1 dw,,\ &. h W U22a
Cell Phone:_( ) Land Line: _( 5I9� ) 7LIZ q 37l
Email:
• Engineer(s)•
Name(s):
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line: _( )
Email:
Contact Person for Building & Code Compliance: L61)( NhA WC
Cell Phone: _(Klb ) LJbJ- 1713 Land Line: _( )
Email: QrAup c4_ f!3o T F, W
Principle Structure Packet Revised February 2019
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms: X gallons per =total daily flow
per day bedroom Garbage Grinder Yes
1980 or older 150 Installed? (circle one)
1981-1991 130 Spa or Hot Tub Yes o
Installed? (circle one)
1992-Present 110 3 lllJ 330
PARCEL INFORMATION:
Topography Flat Rolling Steep Slope %Slope
Soil Nature X Sand _Loam _Clay —other(explain: )
Groundwater At what depth? AVA,_ Fp
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 &V 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 r2 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: 1�1 f1 N�(LI DATE:
SIGNATURE: DATE:
Principle Structure Packet Revised February 2019
CHECKLIST-SINGLE FAMILY Project L o c a t i o n : IF
REQUIRED -2 SETS YES NO N/A
1. Building Permit application, completed J
2. Energy Code inspector's report from REScheck, completed & signed
3. Septic alteration application, if applicable
4. Solid Fuel Burning or Gas Appliance form completed, if applicable
5. Driveway Permit, if applicable
6. Structural Drawings:
a. Floor plans
b. Foundation plans
c. Cross Sections
d. Elevations
e. Window & Door Schedule
f. Natural Light,Ventilation & Emergency Egress
7. Plot Plan: Show proposed structure(s) with setback dimensions
from all surveyed property lines
8. Electrical inspection agency selected
CHECKLIST- MULTI-DWELLING/COMMERCIAL Project Location:
REQUIRED -2 SETS YES NO N/A
1. Building Permit application, completed
2. Energy Code inspector's report from COMcheck, completed &
signed
3. Septic alteration application, if applicable
4. Solid Fuel Burning or Gas Appliance form completed, if applicable
5. Driveway Permit, iP applicable
6. Structural Drawings:
a. Floor plans
b. Foundation plans
c. Cross Sections
d. Elevations
e. Design loads including floor, snow&wind load
f. Seismicdesign
g. Plans signed & sealed by registered architect or engineer
h. Window & Door schedule
7. Plot Plan: Show proposed structure(s}with setback dimensions
from all surveyed property lines
8. Electrical inspection agencyselected
9. FINALAS-BUILT PLANSSUBMITTED ELECTRICONICALLY
Principle Structure Packet Revised February 2019