application J`
Office Use Only
ACCESSORY STRUCTURE
PERMIT APPLICATION Permit#: S=— 55 iQ ^ L4/7�
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Town of Queensbury Permit Fee:$ `0 k
742 Bay Road,Queensbury,NY 12804
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P:518-761-8256 www.gueensbury.net Invoice#:
Project Location: /A &Zkz,e>�
Tax Map ID#: ,S09, I I — I —.!23_ Subdivision Name:
• � s EE
MMCONTACT INFORMATION:
A licant•
Name(s): 10
I ILlJilS '� C�01`?E�
Mailing Address, C/S/Z: _
Cell Phone: ( 5J k )_ - Land Line:
Email: b i L
• Primary Owner(s):
Name(s):
Mailing Address; C/S/Z:
.Cell Phone:�_) Land Line: � )
Email:
XCheck if all work will be performed by homeowner only
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor 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:
Cell:Phone: ( ) Land Line:
Email:
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:
i J
1st floor: �
2nd floor:
Total square feet:
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$ 9, 71000
2. If Commercial project,what is the proposed use:
3. Are there any structures not shown on the plot plan? YES Explain:
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. Ifthework is not completed by the 1 year expiration date the permit may be renewed, subject to fees
and department approval.
3. 1 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. 1 acknowledge that prior to occupying the facilities proposed I, or my agents, will obtain a certificate of
occupancy.
5. 1 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:
SIGNATURE: DATE: "I P
Accessory Structure Application Revised February 2019
REQUIREMENTS FOR SUBMITTAL:
1. Completed Accessory.Structdre permit application
TWO(2)COPIES OF THE FOLLOWING:
2. Structural drawings,which include:
a. Si ned &.sealed architect or engineer stamp IF the cost of,construction is over$20,000
-b.--Floor plan
t c._foundation plan
d. Cross sections
e. Elevations
f. Window&Door schedules—,printed on the drawings is acceptable
g. Calculation sheet for natural light,ventilation &emergency egress
3. Plot plan, using a survey map if possible,which includes:
a. Drawn to scale (i.e. 1 inch'=30 feet)
b. Indicate proposed changes, with setbacks
c. Include all structures on the property
d. Include location of water supply(well or water lines)
e. Include location &configuration of septic system or sewer line
4. REScheck(residential projects) or COMcheck(commercial projects), signed and stamped—
www.energycodes.gov
5. Workers' Comp insurance information for all contractors involved.
ADDITIONAL INFORMATION:
1. Any changes to the approved plans prior to or 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, 20%of the fee is retained by the
Town of Queensbury. After 1 year from the initial application date, 100%of the fee is retained.
Accessory Structure Application Revised February 2019
-7
TOWN OF QUEEIN86URY
BUILDING DEPARTMENT 00 0 9 2020
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