AST-0494-2021 r
j Office Use Only
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ACCESSORY STRUCTURE Permit#: P6T 0" ' 29 Z)
Town ofOuccnsbury PERMIT APPLICATION Permit Fee:$ 85
742 Bay Road,Queensbury,NY 12804 Invoice#: [
P:518-761-8256 www.gueensbury.net Flood Zone? Y N Reviewed By:ms__
Project Location: �� 12, 0,f3 ref
Tax Map ID M Subdivision Name:
PROJECT INFORMATION: D C E 0 BUJ IE
TYPE: L"I Residential ❑ Commercial, Proposed Use: ,SUN 3 O 202
TOWN OF QUEENSBURY
STRUCTURE: BUILDING& CODES
❑ Boathouse(with or w/o sundeck) ❑ Canopy ❑ Carport ❑ Cell Tower ❑ Deck
❑ D ached Garage(>300 s.f.) El Dock ❑ Gazebo El Pavilion ❑ Pole Barn ❑ Porch ❑ Ramp
Shed(<300 s.f.) ❑ Solar Panels(w/o rafter upgrades) ❑ 3-Season Porch ❑ Other:
SQUARE FOOTAGE OF STRUCTURE:
1st floor: y
2nd floor:
Total square feet:
Brief description of scope of project:
ay.2 sf' ,
Accessory Structure Application l ' Revised January 2021
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ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$
2. Are there any structures not shown on the plot plan? DYES NO Explain:
3. Are there any easements on the property? ❑ YES /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 If,for any reason,the building permit application is withdrawn,30%of the fee is retained by the Town of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 I, 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 prior to issuance of a certificate of occupancy.
have read and agree to the above:
PRINT NAME: 2af�' �
01
SIGNATUR@cif- DATE:
Accessory Structure Application Revised January 2021
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CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): r4me,,-r- ,b�.,ep .� ,rh4ezre.2
Mailing Address; C/S/Z: 3d !•�1� r 9J�y �.ry �sg'�r�
Cell Phone: d7f Land Line:
Email: Ayc,-�V Ar-w sv-�(
Primary Owner(s):
Name(s):
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
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"
• Arch itect(s)/Eneineer(sl:
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: 14�� "C
Email:
Accessory Structure Application Revised January 2021