AST-0710-2020 Office Use Only.11 ACCESSORY STRUCTURE yam,
PERMIF.APPLICATION Permit#: P:S� O 2A2
Town of Queensbury Permit Fee:$ `
742 Bay Road,Queensbury,NY 12804'.
P:518-761-8256 www.queensbury.net Invoice#: 31 -
Project Location: 73 S E--E y g pv
Tax Map ID#: 2 2 7, /7 - ,_ 3y Subdivision Name:
CONTACT INFORMATION:
• Applicant:
Name(s): $ e o t7- ( - G-V/ /v5
Mailing Address, C/S/Z: 7'7 W0a37/ ST t4PT 3 R JVEtv Year 11.Y, 100/3
Cell Phone: ( 3117 ) 3 's7 - 7069 Land Line: (
Email: S cc'7T IEV ti5 /D ®X , Cowl,
• Primary Owner(s):
Name(s): NOV 12 2020
Mailing Address, C/S/Z: TOAN OF QUEENSBURY
Cell Phone: ( ) Land Line: ( OUILnING 8,CODES
Email:
❑ Check if all work will be performed by homeowner only
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): 'GZ4A1 k Da-Nr46Wv 17 3,9 t L,ra I90c,A: @(1, (LC-
Contractor Trade: i3U, is:s
Mailing Address, C/S/Z: /2 Q 62X a y/ decvr: my, /2 f2
Cell Phone: (17 S ) 716 -/c/g-ii Land Line: ( f/c ) 6 S6 3C.2 r'
Email: Eci pdf eo
**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:
Y
Contact Person for Building&Code Compliance: GL�A-1✓k 0CAG,Da
Cell Phone: (5/ ) ��: —/'/ Land Line: (5`/ ) 65
Email: Li Pock-co 62e7d3/L , CO/4,
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 _Paiilion, Pole Barn,Canopyock _Gazebo
Detached Garage 1.✓Boathouse(with or w/o sundeck) _3-Season Porch
Other(description:
SQUARE FOOTAGE OF STRUCTURE:
1st floor: (r?S Poc-/C
2nd floor: 560 / f
Total square feet: 1226
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$ A goo
2. If Commercial project,what is the proposed use:
3. Are there any structures not shown on the plot plan? YES 1WExplain:
4. Are there any easements on the property? YES
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: fr2 O/ /C OE. N/9340®
SIGNATURE: A4a,"-rlek-- -.- DATE: /0
Accessory Structure Application Revised February 2019
e21/2020 Query results
Y No K Lake George
rSTATE Park Commission
75 Fort George Road,P.O.Box 749,Lake George,NY 12845 1518.668.9347 Fax:518.668.5001 I www.lgpc.state.ny.us info@lgpc.state.ny.us
NOTICE OF AVAILABILITY FOR REVIEW
Date: 09/21/2020
TO INTERESTED PARTIES: Comments Due: 10/06/2020
This notice is being sent to allow you an opportunity to comment on the proposed project below. Written
comments must be received by the "comments due" date above and should detail specific reasons for your
interest. support or opposition.
If you have no comments then no action is required.
Follow the instructions below to submit your comments online or submit them through email or mail to the above
address, the analyst assigned is:
Roger Smith, rsmith@Igpc.state.ny.us
Applicant: EVANS, SCOTT C Application#: DWM20-000054
79 Worth St Apt 3R Type: 01. Docks, Wharfs, and Moorings
New York NY 10013
Parcel #: 227.17-1-34
Project Location: 73 Seelye Road Queensbury
Project Description: Modify a dock to result in a 40' long by 26'wide, U-shaped dock with a sundeck.
State Environmental Quality Review Lead Agency: Not Designated
SEQR Determination: 1 -Type II Action, no further review under SEQR
If you have any comments or would like to review the plans visit our portal:
https://www3.citizenserve.com/Igpc
To find the plans go to the Search, select Permits from File Type, enter"DWM20-000054" into the Permit#field,
click search, and click the Permit#. Here you can review the application and if you navigate to the Documents tab
you can find the plans.
To submit any comments go to the Reports tab, open the "Public Comment" report, enter"DWM20-000054" into
the Application #field, your name, your address, and your comment. Click Run and your comment will be sent to
the Commission for review.
cc: Queensbury, Adirondack Park Agency, all neighbors within 0.0 feet
3 2020 �'
NOV 1 a_
TOWN OF QUEENS"� _.
BUILQ1f�lO_�� �' 227.17-134 AST-0710-2020
Evans, Scott
73 Seelye Rd
Dock 665 s.f. and sundeck 560 s.f.
https://www3.citizenserve.com/Admin/ReportController
(1°1—‘
NEWYORK (b i' s. « LULU (1,lake Geor e 6fSTATE OF ?k t/ Vikj
OPPORTUNITY. Park Commission ip •
75 Fort GeorgeRd,PO Box 749,Lake George NY 12845 1518.668.93 47 fax 518.668-5001 I info chi Igpc.state.ny.us www.lgpc.state.ny.us
APPLICATION FOR PERMIT FOR DOCKS, WHARFS AND MOORINGS
THIS APPLICATION IS FOR THE: (check all that apply)
❑ Construction of a New Dock or Wharf ($200) ❑ Placement of a Mooring ($100)
tiModification to an Existing Dock or Wharf($50) ❑ Modification to an Existing Mooring ($50)
Article 15 (Repair, removal, replacement or installation of cribbing as part of wharf construction)
APPLICATION FEE ENCLOSED: (check or money order only)
1. OWNER pr. 0 Mrs. 0 Ms. ❑Dr. ❑ INDIVIDUAL 0 PARTNERSHIP 0 ASSOCIATION
0 CORPORATION 0 MUNICIPALITY ❑ AGENCY
NAME 5 �r- C, Ev/ N S EMAIL scott. m.. e box. c c-,�w
CONTACT PERSON IF OWNER IS NOT AN INDIVIDUAL
MAILING ADDRESS ?7 (,'o C4-e,. S+• 4P71Q-
CITY y,.rLG. STATE fl/1/' ZIP CODE /Oo 3 PHONE 311 -136- 7O6.
**If this is an association or if other parties have deeded or contractual access to this lakefront,please complete Addendum A**
(
2. AGENT 0 NONE PRESIDENT OR CEO 0 LLC MEMBER 0 ATTORNEY 0 CONSULTANT 0 CONTACT PERSON
NAME F/114N/C ,�e./yam EMAIL 647-4,415c.41-00 ( ed.",
COMPANY '4/j-• j)e cy yhArgriu Z..L.�,
MAILING ADDRESS re), f)
CITY ezeu- 61, ( - STATEJyy ZIP CODE/2020 PHONE./ 6s"e'.5 j'
3. CONTRACTOR (If known)
NAME ,� j EMAIL
COMPANY
MAILING ADDRESS
CITY STATE ZIP CODE I PHONE
4. PROJECT LOCATION _ _
TOWN 0 TICONDEROGA 0 DRESDEN SECTION^'. 1 7I BLOCK f LOT 3
❑ FORT ANN 0 HAGUE o�{c I 7
❑JAKE GEORGE 0 PUTNAM STREET w'QUEENSBURY 0 BOLTON 73
LAKE FRONTAGE /,2 6 feet NUMBER OF WHARFS AND MOORINGS CURRENTLY ON PROPERTY
according to Tax Map 0 Survey(attach copy) l DOCKS MOORINGS (Please fill in a number or 0 for each)
DOES LAKEFRONT CONTAIN WETLANDS? ❑ Yes 0 No STREAMS?0 Yes ❑No(If yes,show on project plans)
5. PROJECT DESCRIPTION Re_,fAcr-)c ( We
PROJECT DESCRIPTION /) /V14-1 /�Or,�� 'i` �G✓V✓ �-�C /�� 1����
U:ISHAREDILGPC Program-Environmental Permits\Forms1Docks&Mooringslwharfmoo•wpd 7/3/19 Page 1 of 2
•
��
PROPOSED USE Ei'RESIDENTIAL 0 COMMERCIAL 0 ASSOCIATION ❑ PUBLIC
TYPE OF CONSTRUCTION ❑STAKE pso6RIB 0 PILE ❑ARTICULATING ❑OTHER
0 CANOPIED BOATLIFT 0 UN-CANOPIED BOATLIFT ❑PWC LIFT (include manufacturer specification sheet for all lifts)
PROPOSED STARTING DATE PROPOSED COMPLETION DATE
IS ANY PORTION OF THIS ACTIVITY FOR WHICH A PERMIT IS SOUGHT NOW BEGUN OR COMPLETED?
❑ Yes No (if yes,please explain)
IF COMMERCIAL,IS THE FACILITY AND ITS ASSOCIATED LAND USES IN COMPLIANCE WITH APPLICABLE
PROVISIONS OF STATE AND LOCAL LAWS,ORDINANCES, RULES AND REGULATIONS?
❑Yes ❑No(if no,please explain)
6. ADJOINING LAKEFRONT PROPERTY OWNERS (available from your town or county real property dept.)
NAME ;Tl3Mi%S /t ,9//eAN NAME Wily/yg /LLr,'rn5
TAX MAP# Z;2 J 7 / �� TAX MAP# � 7 /7.--. gs
MAILING MAILING �"
ADDRESS /U Pi�l✓SCAV GT ADDRESS 7 :�r�i` 2 Li/
(Vh1rF Pinks N y, /06O 7 CLE -t' /2 V
7. CERTIFICATION
I hereby affirm that the information on this form and all attachments submitted herewith is true to the best of my
knowledge and belief.
I hereby consent to the Commission staff working directly with my agent, as designated on page 1 of this form,during
the review of this application.
During the processing of this application Lake George Park Commission (LGPC) personnel or their assigns may need
to visit this site to inspect, measure, make drawings and/or take photographs. I hereby agree that LGPC staff or their
assigns may enter upon and pass through this property in order to inspect the project site or facility,without prior
notice, between the hours of 8:00 a.m. and 5:00 p.m., Monday through Friday,while the application is pending. In the
event that the project site or facility is posted with any form of"posted"or"keep out"notices, or fenced in with an
unlocked gate,this permission authorizes LGPC staff or their assigns to disregard such notices or unlocked gates at
the time of inspection.
As a condition to the issuance of a permit, the applicant accepts full legal responsibility for all damage, direct and
indirect, or whatever nature, and by whomever suffered, arising out of the project described herein and agrees to
indemnify and save harmless the State from suits, actions, damages and costs of every name and description
resulting from the said project.
SIGNATURE F OWNER(Note title if signing for a corporation or association) DATE
�--- E5 f ie2 /2o
PLEASE COMPLETE ALL ITEMS ABOVE AND INCLUDE WITH THIS FORM:
❑ Application fee
❑ Site location map
❑ Copy of survey if available
❑ Project plans on 81/2 X 11 size paper-PLANS MUST BE TO SCALE&SHOW ENTIRE LAKEFRONT
❑ Short Environmental Assessment Form if project involves
• A new Association or Commercial dock or mooring
• More than one residential dock or mooring
• A dock or mooring to be located in a wetland,fish spawning area, an area of significant
wildlife habitat, or an area of unique scenic, historic or natural significance
❑ Addendum A Co-owner Signature Page(if lakefront is jointly or commonly owned)
Cl Addendum B Parties with deeded or contractual access to this lakefront
Failure to include any one of the required items will result In an Incomplete notice and delay in processing your application. Permits
and approvals may be required from other agencies and municipalities
U:ISHAREDILGPC Program-Environmental Permits\Forms\Docks&Mooringslwharfmoo.wpd 7/3/19
Page 2 of 2
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