application imb
k17yc
Office Use Only
ACCESSORY STRUCTURE
Permit#: �‘ �5i
PERMIT APPLICATION
Town of(Zuccnshury I
742 Bay Road,Queensbury,NY 12804 Permit Fee:$2y"dZ,
P:518-761-8256 www.queensbury.net Invoice#: 1 "- e)
Project Location: 5`) 110
Tax Map ID #: C/ a ! ` / — 9 Subdivision Name:
CONTACT INFORMATION:
• Applicant:
Name(s): 2.; v
Mailing Address, C/S/Z: 3 g wok r 1`5
Cell Phone: ( ¶"/E ) Z-Y— 9 Z-7 6 Land Line: (
Email: ICI - 111661 5.&1041- Co,,
• Primary Owner(s):
Name(s): S.v- z A-- Pt\s
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: (
Email:
Check if all work will be performed by homeowner only
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: }----R—
Email: c E Sl 15
**List all additional contractors on the back
jut_ 022019
• Architect(s)/Engineer(s):
Business Name: FQUECNSBURY
Contact Name(s): BUI►_DI N_�
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: (
Email:
Contact Person for Building & Code Compliance:
Cell Phone: ( ) Land Line: (
Email:
Accessory Structure Application Revised February 2019
1
'rf r
PROJECT INFORMATION:
TYPE: Commercial S Residential
WORK CLASS:
Deck,Open Porch Solar Panels(w/o rafter upgrades) _Carport _Cell Tower
Shed Pavilion, Pole Barn,Canopy _Dock _Gazebo
Detached Garage _Boathouse(with or w/o sundeck) _3-Season Porch
Other(description:
SQUARE FOOTAGE OF
OF STRUCTURE:
1st floor: GOO
2"d floor: ``
Total square feet: F�iO
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$' 1®00
2. If Commercial project,what is the proposed use: Pew
e— \
3. Are there any structures not shown on the plot plan? YES NO Explain: Peeep 14 Per-47/
4. Are there any easements on the property? YES
DECLARATION:
1. I acknowledge that no.construction shall be commenced prior to issuance of a valid permit and 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 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. I acknowledge that prior to occupying the facilities proposed I, or my agents, will obtain a certificate of
occupancy.
5. I also understand that I/4ve 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.
1 have read and agree to the above:
PRINT NAME: St "L e•-•'
SIGNATURE: DATE -7"1"
Accessory Structure Appllcati Revised February 2O.9.
REQUIREMENTS FOR SUBMITTAL:
1. Completed Accessory Structure permit application
TWO(2) COPIES OF THE FOLLOWING:
2. Structural drawings, which include:
a. Signed & sealed architect or engineer stamp IF the cost of construction is over$20,000
b. Floor plan
c. Foundation plan
d. Cross sections
e. Elevations
f. Window& Door schedules—printed on the drawings is acceptable
g. Calculation sheet for natural light,ventilation &emergency egress
3. Plot plan, using a.survey map if possible,which includes:
a. Drawn to scale (i.e. 1 inch =30 feet)
b. Indicate proposed changes, 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
4. REScheck(residential projects) or COMcheck(commercial projects), signed and stamped—
www.energycodes.gov
5. Workers' Comp insurance information for all contractors involved.
ADDITIONAL INFORMATION:
1. Any changes to the approved plans prior to or during construction will require the submittal of
amended plans, additional reviews and re-approval.
2. If,for any reason,the building permit application is withdrawn, 20%of the fee is retained by the
Town of Clueensbury. After 1 year from the initial application date, 100%of the fee is retained.
Accessory Structure Application Revised February 2019