application Office Use Only
ACCESSORY STRUCTURE Permit#: 1-855�' Z�tS
PERMIT APPLICATION Permit Fee:$ 12�
Town of(Zcensbury
742 Bay Road,Queensbury,NY 12804 Invoice#: 1°2-LQ
P:518-761-8256 www.queensbury.net
Project Location: _16 Algonquin Dr.
Tax Map ID #: 301 • 1 3 2 -l,?S Subdivision Name:
CONTACT INFORMATION:
• Applicant:
Name(s): _Dave Mahoney
Mailing Address, C/S/Z:154Algonquin Dr
Cell Phone: _(_518 )_791-9484 Land Line: _(_518 )_792-4047
Email: _dmahoney123@roadrunner.com
• Primary Owner(s): D
Name(s): _Samual , �C,/€,2 �
Mailing Address, C/S/Z: 16 Algonquin Dr AVG 7O 2019
Cell Phone: ( � P' ) 5' -. 2.S3 Land Line: _( TOWN OF
Email: BDtLDtN�DEENSBURY
& CODES
❑ Check if all work will be performed by homeowner only
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contact Name(s): R\kCant
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _( ) __
Email:
**List all additional contractors on the back of this form
• Architect(s)/Engineer(s):
Business Name:
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _(
Email:
Contact Person for Building & Code Compliance: 4-10\ c YNT-
Cell Phone: _( ) Land Line: _( I )
Email:
Accessory Structure Application Revised February 2019
PROJECT INFORMATION:
TYPE: ❑ Commercial ® 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:_handicap ramp
SQUARE FOOTAGE OF STRUCTURE:
1st flooi: '%5 2 S ti
2nd floor:
Total square feeet: 2/ s I,,-
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ $3000
2. If Commercial project, what is the proposed use:
3. Are there any structures not shown on the plot plan? YES NO Explain:
4. Are there any easements on the property? ❑ YES ►1 NO
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/we 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.
I have read and agree to the above:
PRINT NAME: Di9✓ d / 4Hun/d y
SIGNATURE --", DATE: ?"/
Accessory Structure Application Revised February 2019