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application Office Use Only ACCESSORY STRU F ° �`F Imo_,i_. rPe 'i AST- 027:1 Z 1E PERMIT APPLICATI I er i $ G° Town of Queensbury t APR 1 2)�� pp 742 Bay Road,Queensbury,NY 12804 I s -invdice#: :' q37 P:518-761-8256 www.queensbury.net TOWN OF OUEENSBURY l a BUILDING & OI.)E : Project Location: 74 Sara-Jen Dr., Queensbury, NY 12804v Tax Map ID #: _523400 295.10-1-48 Subdivision Name: Lehland Estates CONTACT INFORMATION: • Applicant: Name(s): Patrick Pepin Mailing Address, C/S/Z: 74 Sara-Jen Dr., Queensbury,NY 12804 Cell Phone: _(_518 )_791-0556_ Land Line: _( 518 ) 792-4833 Email: ppepin@roadrunner.com • Primary Owner(s): Name(s): Patrick Pepin_ Mailing Address, C/S/Z: _74 Sara-Jen Dr., Queensbury,NY 12804 Cell Phone: _(_518_)_791-0556 Land Line: ( 518_)_792-4833 Email: ppepin@roadrunner.com ❑ Check if all work will be performed by homeowner only • Contractor(s): Workers' Comp documentation must be submitted with this application Contact 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: Garden Time Inc Contact Name(s): Tom McMillen Mailing Address, C/S/Z: 652 Quaker Road, Queensbury, NY 12804 Cell Phone: _( ) Land Line: _( 518_)_793-8555 x327 Email: tomm@gardentimeinc.com Contact Person for Building & Code Compliance: _Tom McMillen Cell Phone: _( ) Land Line: _(_518_)_793-8555 x327 Email: tomm@gardentimeinc.com 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: SQUARE FOOTAGE OF STRUCTURE: 1st floor: 192 2nd floor: N/A Total square feet: 192 ADDITIONAL PROJECT INFORMATION: 1. Estimated Cost of Construction: $ 6864 2. If Commercial project, what is the proposed use: 3. Are there any structures not shown on the plot plan? YES X 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:_Patrick Pepin SIGNATURE: (z Z DATE: 4/18/19 Accessory Structure Application Revised February 2019