RC-0301-2022 Office Use Only
MANUFACTURED HOME Permit#:
PERMIT APPLICATION
~--�_ Permit Fee:$
Town of Queensbury
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.gueensbury.net Rec Fee:$
Invoice#:
Project Location: %2 , /��Mon �� Flood Zone? Y Reviewed By'.�
_) �/
e
Tax Map ID#: 309. !q - 3-57
Name of Park(if applicable):
PROJECT INFORMATION: T MAY 18 202
1. Proposed Date of Placement: 'I BU OF QUFF
2. Approximate Value of Home:$ C�FSRY
3. Is the home NEW ✓ or a REPLACEMENT ?
4. Single-wide /or Double-wide Size: j-l—ft.X 66 ft._ /d total square feet
5. Foundation support(choose one): Size Depth
Piers:
Slab: IAX
6. Is the home being placed on a private lot? No Yes**
(**if yes,you must provide stamped engineered drawings of the permanent foundation plan)
7. Total'#of rooms(exclude bath7yes
): ;#of bedrooms: ;#of bathrooms:
8. Additional heat source? No Choose one, if yes: gas fp_ woodstove_ wood fp
9. Are there any other/.existing buildings on the property? No V Yes ; Explain:
10. What is the water source? PUBLIC_Z PRIVATE WELL
11. What type of wastewater system is on the parcel? SEWER PRIVATE SEPTIC_A/
12. Do you need a septic permit application? No Yes
MANUFACTURED HOME INFORMATION:
(INFORMATION FOUND ON THE PLATE OR STICKER LOCATED IN THE HOME): �n
Insignia serial#: 0 97 ION N FA
Name of Manufacturer: • -s '
Place approval#:
Model or component designation (New Home Only):
Date of manufacture:
Manufactured Home Application Revised January 2021
t
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant: /
Mailing Address, C/S/Z: jkn HVCY1vte - 61-S +p o
Cell Phone: ,j/ ) g/ _ C06 O Land Line: ( Y127
Email: _►''cam f , f F o Ca�'1
• Primary Owner(s): 1
Name(s): SOLM e aS n
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
Check if all work will be performed b the property owner only
p Y p p Y fit'.
• Contractor(s): (List all additional contractors on the back of this form)
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
"Workers' Comp documentation must be submitted with this application"
Contact Person for Compliance in regards to this project: ta' 0 �c 1.
Cell Phone:J ) Land Line: �)
Email:
Manufactured Home Application Revised January 2021
REQUIREMENTS FOR SUBMITTAL:
1. Completed Manufactured Home permit application
THREE (3) COPIES OF THE FOLLOWING:
2. Structural drawings, which include:
a. Floor plan
b. Foundation plan (see 2015 IRC Appendix E Section AE502:foundation systems)
.c. If the home is being placed on a private parcel (not in a manufactured home park or designated
zone),you MUST provide stamped engineered drawings of the permanent foundation plan.
3. Plot plan, using a survey map if possible,which includes:
a. Drawn to scale (i.e. 1 inch = 30 feet)
b. Indicate proposed location, with setbacks
c. Include all structures on the property
d. Include location of water supply(well or water lines)
e. Include location &configuration of septic system or sewer line
ADDITIONAL SUBMITTAL INFORMATION:
1. Installer Warranty seal must be provided prior to issuing Certificate of Occupancy.
2. Any changes to the approved plans prior to or during construction will require the submittal of
amended plans, additional reviews and re-approval.
3. If,for any reason, the building permit application is withdrawn, 30% of the fee is retained by the
Town of Queensbury. After 1 year from the initial application date, 100% of the fee is retained.
4. Workers' Comp insurance information for all contractors involved—REQUIRED, EVEN FOR SOLE
PROPRIETORS
DECLARATION:
I'swear that,to the best of my knowledge and belief,the statements contained in this application,together with the
plans and specifications submitted,are a true and complete statement of all proposed work to be done on the described
premises;and,that all provisions of the NYS Building Code,the Zoning Ordinance and all other laws pertaining to the
proposed work shall be complied with,whether specified or not,and that such work is authorized by the owner.
I have read and agree to the above:
PRINT NAME: ( ��.
SIGNATURE DATE: 5
Manufactured Home Application Revised January 2021
-� SEPTIC DISPOSAL PERMIT Office Use Only
APPLICATION Permit#: ?--C - � - ZO 2
Town of Ouccnsbum
Permit Fee:$
Invoice#:
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.gueensbury.net Septic Variance? Y
Flood Zone? Y
Wetlands? Y ( -Reviewed By. . �f+�
Project Location: 13 't ri on+ ��� `r ' U '
Tax Map#: 309,9 -- -6-7 [MAY 182022
RESIDENCE INFORMATION: TOWN OF QUEENSBURY
Year Built Gallons #of bedrooms: X gallons per total daily flow BUILDING&CODES
per day bedroom Garbage Grinder Yes No
1980 or older 150 Installed? (choose one) ❑ 91,
1981-1991 130 9 Spa or Hot Tub Yes No
1992-Present 1110 j installed? (choose one) I ❑
PARCEL INFORMATION:
Topography Flat Rolling ❑ Steep Slope % Slope
Soil Nature 15sand ❑ Loam ❑ Clay ❑ Other, explain:
Groundwater At what depth?
Bedrock/Impervious material At what depth?
Domestic Water Supply 200Municipal ❑Well ❑Lake
(if well or lake, water supply from any septic system absorption is
ft.)
Percolation Test Rate: per minute per inch (test to be completed by a
licensed engineer/architect)
PROPOSED SYSTEM INFORMATION:
Tank size /COO gallons (min. size 1,000 gallons, add 250 gallons for each garbage cylinder or
sp�t tub
System Absorption field w/#2 stone Total length ft.; Each Trench Lft.
Seepage Pit w/#3 stone How many: ; Size:
Alternative System Bed or other type:
Holding Tank System Total required capacity? ; tank size ;
# of tanks
Septic Application Revised April 2021
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): t'`r�►rGlId l_
l�� c O.Y. I ��� I
Mailing Address, C/S/Z: /D %3oJktw,n� eve Cr�eYtS Fa 11S
Cell Phone: SIY I — 00(0 0 Land Line: (S)Ft o`ZJ.3-69>7 6
Email: e,rc.� yet �Mcc� Cpn'�
• Primary Owner(s): 1
Name(s): borne c.5
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
Check if all work will be performed by property owner only
• Contractor:
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
**Workers' Comp documentation must be submitted with this application**
• Eneineer(s)•
Name(s):
Mailing Address; C/S/Z:
Cell Phone: Land Line:
Email:
Contact Person for Compliance in regards to this project:
Cell Phone: Land Line:
Email:
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.4. If, for any reason, the building permit application is withdrawn, 30% of the fee is retained by the
Town of Queensbury. After 1 year from the initial application date, 100% of the fee is retained.
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.
t
PRINT NAME:
SIGNATURE: - DATE:
Septic Application Revised April 2021
TOWN OF OUEENSBURY
74-2 Bay Road, Queensbury, .IVY. 12804-5902
Septic System Checklist
Plan to scale
)-6I1eceived Deep hole perc test results from engineer/Architect if applicable(Town Approved Engineers and
Architects;June 30 to April 15 Town Engineer for unapproved Engineers and Architects)
""'All wells.on property and adjacent properties shown
I&Water line shown Municipal or well 10'separation to any part of system
Setback to property lines show 10'or more for any part of system
9Septic tank and pump stations 10'from foundation 50'from any well/lake/wetland 10'from any waterline
P_j6eptic tank to foundation crawl space/slab on grade,grade in crawl space must be above top of septic tank
for 0',Separation required (field verification required)
Aiseptic tank sized for number of bedrooms and add 250 gals forJacuzzi tubs/garbage grinder each
Aeech Field 20'from foundation 100'from any well 10'from water line
ASeepage pit 150'from well 50'from septic tank
teepage Pits 3-times diameter apart
6Septic tank and pump stations over 30 gallons 50'from watercourse or wetland
91distance from bottom of trench or system 24"to bedrock or mottling 36"within 1000'of Lake George
q' Leech
field 100'from watercourse or wetland
I+Toe of mound or bottom of retaining wall 10'from property line 100'from well 20'from
Foundation
Provide Engineer/Architect stamp for bed or design systems
PADepartmentof Health Approval for all mobile home park new systems Flood Plain requirements
2'above established flood elevation to bottom of system
0AII tanks anchored or 2' above flood elevation
P—riaarl All IMI)II
Aug, 2. 2022A11_19A MDIA No. 9828 P. 6/6
MIDDLE DEPARTMENT INSPECTION AGENCY, INC.
�rfr that the electrical wiring to the electrical equipment listed below has been examined and is approved as
being in accord with the National Electrical Code, applicable governmental, utility and Agency rules in effect on the date
noted below and is issued subject to the following conditions,
Owner: Gerald Baker Date:
07/27/2022
Occupant:
Mobile Home Location-
Occupancy:
Vermont Ave.
OccupancrServices Queensbury, Warren Co. NY
Applicant:
Gerald Baker
10 Baldwin Ave.
Glens Falls, NY 12801••'
L _J
Joseph A.Holmes.
318014171 1 33_EL
Equipment:
200 Amp. Service Equipment;4/0 Service'Cohdtictdr,'100"Amp. Feeder'to'Home
rr-
::. ..... OF QuEP f
BUILD/ CL'SP,Y
This certificate applies to the electrical wiring to the electrical equipment listed immediately null and void. This certificate applies only to the use,occupancy and
above and the Installation inspected as of the above noted date based on a visual ownership as indicated herein. Upon a change in the use,occupancy or ownership
inspection. No warranty is expressed or implied as to the mechanical safety,effi• of the property Indicated above,this certificate shall be immediately null and void.
ciency or fitness of"ecuo rent for any particular purpose. This certificate shall In the event that this certificate becomes invalid based upon the above condIllons,
be valid for a period of one year from the above noted deft. Should the electrical this certificate may be revalidated upon reinspection by Middle'Department
system to which Utis certificate applies be altered in any way,including but not limit- Inspection Agency,Inc. An application for Inspection must be submitted to Middle
ed to,the introduCtfon of additional electrical equipment and/or the replacement of Department Inspection Agenoy. Inc.to initiate the inspection and rsValidatien
any of the components installed as of the above note0 date,this certificate shall be process. A lee will bs charged for this sconce.