AST-0291-2021 Office Use Only
ACCESSORY STRUCTURE Permit#: -ArST- 2.Z/2-I
Town ofQueens6ury PERMIT APPLICATION permit Fee:$
742 Bay Road,Queensbury,NY 12804 Invoice#: 3(ol-C)
P:518-761-8256 www.gueensbury.net Flood Zone? Y N Reviewed By:
Project Location: i `G l
Tax Map ID#: Subdivision Name:
VIE
PROJECT INFORMATION: �D 0
TYPE: 1A Residential ❑ Commercial, Proposed Use: APR 2 8 2021
TOWN OF QUEENS13URY
STRUCTURE: BUILDING&..CODES
❑ Boathouse(with or w/o sundeck) ❑ Canopy ❑ Carport ❑ Cell Tower 09 Deck
❑ Detached Garage(>300 s.f.) ❑ Dock ❑ Gazebo ❑ Pavilion ❑ Pole Barn ❑ Porch ❑ Ramp
❑Shed(<300 s.f.) ❑Solar Panels(w/o rafter upgrades) ❑ 3-Season Porch ❑Other:
SQUARE FOOTAGE OF STRUCTURE:
1st fl
2nd floor:
Total,square feet:
Brief description of scope of project: `
Accessory Structure Application Revised January 2021
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$ %J 00-0, 0 0
2. Are there any structures not shown on the plot plan? ❑YES ®NO Explain:
3. Are there any easements on the property? ❑YES t)-a NO
DECLARATION:
1. 1 acknowledge that no construction shall be commenced prior to the issuance of a valid permit and will be
completed within a 12 month period.Any changes to the approved plans prior to/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 If,for any reason,the building permit application is withdrawn,30%of the fee is retained by the Town of
Queensbury.After 1 year from the initial application date,100%of the fee is retained.
3. Ifthework is not completed by the 1 year expiration date the permit may be renewed, subject to fees_
and department approval.
4. 1 certify that the application, plans and supporting materials are a true and a 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.
5. 1 acknowledge that prior to occupying the facilities proposed 1, or my agents, will obtain a certificate of
occupancy.
6. 1 also understand that I/we are required to provide an as-built survey by a licensed land surveyor of all newly
constructed facilities priorto issuance of a certificate of occupancy.
I have read and agree to the above:
PRINT NAME:Z>
SIGNATURE: �' DATE: Z b O Z
1
Accessory Structure Application Revised January 2021
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): i' ��'� c 2d.�c c ` a 8-0 u\
b �°�a •
Mailing Address,C/S/Z: �TS7 ���. �- , Q-
Cell Phone:S vg-goo --TcoZ 0 Land Line: �-
Email: Q.�&c co I,
• Primary Owner(s):
Name(s): ;�\
Mailing Address, C/S/Z: �0e,&- . Q,��� Y--�sb
Cell Phone:S�Fs-$moo -1b-7 Cand Line:
Check if all work will be performed by property owner only
• Contractor(s): (List all additional'contractors on the back of this form)
Contractor Name(s):
Contractor Trade:
Mailing Address,C/S/Z:
Cell Phone: Land Line:
Email:
"Workers" Comp documentation must be submitted with this application"
• Architect(s)/Enaineeds):
Business Name:
Contact Name(s):
Mailing Address,C/S/Z:
Cell Phone: Land Line:
Email:
Contact Person for any questions regarding this project:
Cell Phone: Land Line:
Email:
Accessory Structure Application Revised January 2021
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