application •
Office Use Only
ACCESSORY STRUCTURE
PERMIT APPLICATION Permit#: -PAST_ p k- 2-D 1�
Town of Queensbury
Permit Fee:$ TJ ,
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net Invoice#: le).5\
Project Location: 74 State Route 149 Lake George, NY 12845
Tax Map ID#: 289.9-1.7.1 Subdivision Na a LS l4a E
CONTACT INFORMATION: JUL 2 3 2t11i
• Applicant: TOWN OF QUEENSBURY
Name(s): David King
BUILDING&CODES
Mailing Address, C/S/Z: Lake George RV Park, Inc. 74 State Route 149 Lake George, NY 12845
Cell Phone: ( ) Land Line:(518)792-3775
Email: dave@lakegeorgervpark.com
• Primary Owner(s):
Name(s):Jessica King Qualified Residence Trust- David King
Mailing Address, C/S/Z: Lake George RV Park, Inc. 74 State Route 149 Lake George, NY 12845
Cell Phone: ( ) Land Line: (518)792-3775
Email: dave@lakegeorgervpark.com
❑ Check if all work will be performed by homeowner only
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): Hilltop Construction Tom Albrecht Jr.
Contractor Trade: General Contractor
Mailing Address, C/S/Z: 51 Crowley Rd Hudson Falls, NY 12839
Cell Phone:_( ) Land Line: _(518)_798-0338
Email: tomjr@hilltopconstructionco.com
**List all additional contractors on the back of this form
• Architect(s)/Engineer(s):
Business Name: Phinney DesignGroup
Contact Name(s): Michael Phinney
Mailing Address, C/S/Z: 142 Grand Ave Saratoga Springs, NY 12866
Cell Phone: _( ) Land Line: (518) 587-7120
Email:mphinney@phinneydesign.com
Contact Person for Building & Code Compliance: Tara Borodin-Galarza
Cell Phone: _( ) Land Line: (518)587-7120 x21
Email:tborodin@phinneydesign.com
Accessory Structure Application Revised February 2019
PROJECT INFORMATION:
x
TYPE: Commercial Residential
WORK CLASS:
Deck,Open Porch Solar Panels(w/o rafter upgrades) Carport _Cell Tower
X Shed _Pavilion, Pole Barn, Canopy _Dock _Gazebo
X Detached Garage Boathouse (with or w/o sundeck) 3-Season Porch
Other(description:
SQUARE FOOTAGE OF STRUCTURE:
1st floor: 540 SF
2nd floor:
Total square feet: 540 SF
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$
40,000
2. If Commercial project,what is the proposed use:
3. Are there any structures not shown on the plot plan? 1)(1t NO Explain:
4. Are there any easements on the property? 11.05 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: IP%)1i) 1&ttsG
SIGNATURE: DATE: 71 - 11'
Accessory Structure Application Revised February 2019