2010-056 TOWN OFQ UEENSBURY
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742 BayRoad,Queensbury,NY 12804-5902 (518)761-8201
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Community Development - Building & Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20100056 Date Issued: Wednesday, November 23, 2011
This is to certify that work requested to be done as shown by Permit Number P20100056
has been completed.
Tax Map Number: 523400-226-019-0001-039-000-0000
Location: FOREST Rd
Owner: LINDA DE LAURA
Applicant: LINDA DE LAURA
This structure may be occupied as a:
Test Pit/Perc Test Review
By Order of Town Board
TOWN OF QUEENSBURY
Issuance of this Certificate of Compliance DOES NOT relieve the ( ' (/ /
property owner of the responsibility for compliance with Site Plan, A ,�f.1 P9'
Variance, or other issues and conditions as a result of approvals by the Director of Building&Code EnforZ4ment
Planning Board or Zoning Board of Appeals.
TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
FO/i.TO
Community Development-Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20100056 Application Number: A20100056
Tax Map No: 523400-226-019-0001-039-000-0000
Permission is hereby granted to: LINDA DE LAURA
For property located at: FOREST 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: LINDA DE LAURA Test Pit/Perc Test Review
163 SHEAR HILL Rd Total Value
MAHOPAC,NY 10541-3631
Contractor or Builder's Name/Address Electrical Inspection Agency
Plans&Specifications
2010-056
DEEP HOLE PERC TEST
$0.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Friday,November 23,2012
(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 To n of Quee bury; ® iWpdnesday,November 23,2011
j
SIGNED BY f
�. + . for the Town of Queensbury.
Director of Building&Co Enforcement
Town of Queensbury• Building&Codes Enforcement Office■742 Bay Road■ Queensbury,NY 12804
DEEP HOLE/PERC TEST
Request for Town Engineer Review
Property Owner: L;roti, ,(./a 144'f p Phone:
Property Owner's />� ��11 �y/
Address: /(,3 S 41 ,j /I / /�'l� !'�n,i0� 4C. Jay ° s5`/
Location of Test: I l,t) G� �i7 er u,4 e / Tax ID#: ��I/ — /
*Applicants Engineer: Ai&e k175 %7 fr,,'mss Phone: 7e76, ;L
Applicant's Agent: 54'47 e 7)3 L:74.3 ince,. Phone:
Additional Notes:
1. Reason for Request? New Septic System IT Replacement Septic System Failed Septic System
Subdivision Site Plan Review
2.Are Wetlands present? g YES 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:
Check No.:
b. •R 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 APPLICANT: a,II Date:
SIGNATURE OF AGENT: Mr____ / Date: g46//61
Original (B&C File) Canary(Planning) Pink(Applicant) Gold (Town Clerk)