application Office Use Only
ACCESSORY STRUCTURE
Permit#: kST - 0-550 • 2z2Z
PERMIT APPLICATION
Permit Fee: $ l25
Town of Qucensbury
742 Bay Road,Queensbury, NY 12804
P:518-761-8256 www.queensbury.net Invoice#: 2-1-Z
Project Location: 116 Burnt Hills Dr
Tax Map ID #: 308.12-1-36 Subdivision Name:_Burnt Ridge
CONTACT INFORMATION:
• Applicant:
Name(s): Gerald Stockman
Mailing Address, C/S/Z: 116 Burnt Hills Dr. Queensbury, NY 12804
Cell Phone: 518-744-4108 Land Line: ( )
Email: istockman12Ca yahoo.com
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• Primary Owner(s): JUN 2 6 2020 1,0
Name(s): Gerald Stockman
Mailing Address, C/S/Z: 116 Burnt Hills Dr. Queensbury, NY 12804 TOWN OF QUEENSBU Y
BUILDING&CODES
Cell Phone: 518-744-4108 Land Line: _( )
Email: istockman12@yahoo.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:
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _( )
Email:
Contact Person for Building & Code Compliance: Gerald Stockman
Cell Phone: 518-744-4108 Land Line: _( )
Email:jstockman12@yahoo.com
Accessory Structure Application Revised February 2019
PROJECT INFORMATION:
TYPE: ❑ Commercial ® Residential
WORK CLASS:
IZ Deck, Open Porch ❑ Solar Panels (w/o rafter upgrades) ❑ Carport ❑ Cell Tower
El 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: 400
2nd floor:
Total square feet:
ADDITIONAL PROJECT INFORMATION:
1.. Estimated Cost of Construction: $4500
2. If Commercial project,what is the proposed use:
3. Are there any structures not shown en the plot plan? YES NO Explain:
4. Are there any easements on the property? ❑ YES II NO
DE_C_LA_R_ATIO TN
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: terd' 1� Sdcies 1 w-
SIGNATURE: 4vtDATE: -6s )-3 2°
Accessory Structure Application Revised February 2019