AST-0605-2019 Offi11 v., isce Use Onl• #: y
\` ACCESSORY . ret
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•� PERMIT AP'
Town of Queensbury P Fee:$ t Z , 0 0
742 Bay Road,Queensbury,NY 12804 SEP 0 5 2019
P:518-761-8256 www.queensbury.net Invoi e#:
TOWN OF QUEENSBURY
Project Location: B DING&CODES
2' ),7 a
Tax Map ID #: •— � - '' Subdivision Name:
CONTACT INFORMATION:
• Applicant:
Name(s): ' dt Qf4— 1MG.Son
Mailing Address, C/S/Z: 5 CAAes *- Rt`d o
Cell Phone: ( 51 ) 7L (f` p-? Land Line: (
Email: r-mass@__\n4' 0.1I. . Ganes
• Primary Owner(s):
Name(s): gou,'"...Q elz.13 apP� ��:•��
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: ( )_
Email:
heck 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: ( )
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: 5 -P�
Cell Phone: ( ) Land Line: ( )
Email: .
Accessory Structure Application Revised February 2019
•
PROJECT INFORMATION: •
TYPE: Commercial -y 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: n LLX 1'Doyv . )
SQUARE FOOTAGE OF STRUCTURE:
1st floor: 1,).
2nd floor:
Total square feet: 7.)
ADDITIONAL PROJECT INFORMATION:
is As
• 1. Estimated Cost of Construction: $ ;.,,. or sr r 42 n0 D
2. If Commercial project,what is the proposed use:
' I
3. Are there any structures not shown on the plot plan? YES NO Explain:
4. Are there any easements on the property? YES 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: - j "So
SIGNATURE: DATE: I// 71/7
Accessory Structure Application Revised February 2019
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 Queensbury. After 1 year from the initial application date, 100% of the fee is retained.
Accessory Structure Application Revised February 2019