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2011-418 iA TOWN OFQUEENSBURY vro 742 BayRoad,Queensbury,NY 12804-5902 (518) 761-8201 Community Development- Building & Codes (518) 761-8256 CERTIFICATE OF COMPLIANCE Permit Number: P20110418 Date Issued: Monday, August 22, 2011 This is to certify that work requested to be done as shown by Permit Number P20110418 has been completed. Tax Map Number: 523400-239-016-0001-020-000-0000 Location: 16 BURNT RIDGE Rd Owner: MYRON, MARK& MASON RAPAPORT Applicant: MYRON, MARK & MASON RAPAPORT This structure may be occupied as a: Test Pit/Pere Test Review By Order of Town Board TOWN OF QUEENSBURY 4 Issuance of this Certificate of Compliance DOES NOT relieve the 6' ' _..... property owner of the responsibility for compliance with Site Plan, "' Variance, or other issues and conditions as a result of approvals by the Director of Building&Codel nforcement Planning Board or Zoning Board of Appeals. TOWN OF QUEENSBURY Foto 742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201 Community Development-Building&Codes (518) 761-8256 BUILDING PERMIT Permit Number: P20110418 Application Number: A20110418 Tax Map No: 523400-239-016-0001-020-000-0000 Permission is hereby granted to: MYRON, MARK&MASON RAPAPORT For property located at: 16 BURNT RIDGE Rd in the Town of Queensbury,to construct or place at the above location in accordance with application together with plot plans and other information hereto filed and approved and in compliance with the NYS Uniform Building Codes and the Queensbury Zoning Ordinance. Type of Construction Value Owner Address: MYRON, MARK&MASON RAPAP Test Pit/Perc Test Review M. GOLDBLATT Total Value 16 BURNT RIDGE Rd LAKE GEORGE,NY 12845 Contractor or Builder's Name/Address Electrical Inspection Agency Plans&Specifications 2011-418 deep hole/perc test $200.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Wednesday,August 22,2012 (If a longer period is required,an application for an extension must be made to the code Enforcement Officer of the Town of Queensbury before the expiration date.) Dated at the Trerr9a£9ueen 'ury! 1 oda August 22,2011 SIGNED BY , '17)% for the Town of Queensbury. Director of Building&Code Enforcement li--LOY Town of Queensbury■ Building&Codes Enforcement Office•742 Bay Road• Que n D ,NY1,7,>iO4_ a i_ 6 2011 DEEP HOLE/PERC TEST TOWN OF QUEENSBUR` Request for Town Engineer Review BUILDING & CODES Property Owner: ill 'han pp ©rt- Phone: OW 656 - 0-505 Property Owner's j 1-7 , 1 Address: I ((b U LII^nt R l d e Road, Location of Test: 16 13Li r'n f Rt ci 9 e Rood Tax ID#: 235 i 6_ I_ 2.© *Applicant's Engineer: 0- L... D ci An SQn / A SSoC- Phone: (I Pl) 66& 46' 6 Applicant's Agent: Phone: Additional Notes: 1.Reason for Request? New Septic System X' Replacement Septic System Failed Septic System Subdivision Site Plan Review 2.Are Wetlands present? YES X NO UNKNOWN *Note: Applicant is required to engage an engineer for design and testing of the system. The Town Engineer's responsibility is to witness system testing only. PLOT PLAN: Plot plan, to scale, to be submitted with application FEE SCHEDULE: a. $200 Flat Fee Date Paid: /62 de</ Check No.: 3 b. OR Fee to be determined during To Be Determined: Site Plan/Subdivision review process SIGNATURE: In carrying out the provisions of Article IV, the Local Board of Health or the enforcement officer may engage the services of a qualified professional consultant for expert review and recommendation arising from the carrying out of the provisions of Art. IV, including but not limited to the review of plans, specifications and reports, attendance at inspections, dye tests, deep hole test pits, septic related deep hole and percolation tests, system installations, and any other aspect of any matter contained in this Art. IV, and any costs incurred in such review shall be paid to the Town by the owner of the property before any approval can be granted under this Art. IV shall become effective within 30 days of presentment of an invoice for same, whichever is sooner. Such costs shall not exceed$1,500 without prior written notice to the party to be charged with same. My signature below indicates I have thoroughly read and understand the instructions, agree to the submission requirements and have completed the application. I also fully understand that additional engineering fees may be necessary per Town of Queensbury Local Law 136-14D. SIGNATURE OF APPLI t'NT: • ,'tel Date: ' MAf Z 1 Mal SIGNATURE OF AGEN & ,,,ii. 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