AST-0513-2021 N
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Office Use Only
ACCESSORY STRUCTURE Permit#: 4S 113���
Town ofQuecnsbury PERI�VI�T�4RPL�CATIDN --pr mit Fee:
p ECEHWE '
742 Bay Road,Queensbury,NY 12804 nice#:
P:518-761-8256 www.gueensbury.net JUL 0 7 Z021 I od Zone? Y N Reviewed By:
TOW OF QUI_ENSBURY
BUiL►DiN;G & CCGES
Project Location: L wi e-,F% c RJ
c ws 10,,-511
Tax Map ID#: 6 23 7 o 0 3 D $ I I ' I" $ Subdivision Name:
PROJECT INFORMATION:
TYPE: Residential ❑ Commercial, Proposed Use:
STRUCTURE:
❑ Boathouse(with or w/o sundeck) ❑ Canopy ❑ Carport [:] Cell Tower ❑ Deck
❑ Detached Garage (>300 s.f.) ❑ Dock ❑ Gazebo ❑ Pavilion ❑ Pole Barn ❑ Porch ❑ Ramp
10 Shed (<300 s.f.) ❑ Solar Panels(w/o rafter upgrades) ❑ 3-Season Porch ❑ Other:
SQUARE FOOTAGE OF STRUCTURE:
1st floor:
JAG
2nd floor:
Total square feet:
Brief description of scope of project: j a
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Accessory Structure Application Revised January 2021
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant: `
Name(s): Vo v1 vi 1~w
Mailing Address, C/S/Z: :3 l X uv e- n e
Cell Phone: 5 r S 7 7 a � 2�'c�4 u
Email: w 6 a
• Primary Owner(s):
Name(s): e-d C4rrs,tzL 1 r��y
Mailing Address, C/S/Z: �g rk I'T
JYew o, l00t�l9 !l/eGyln T21 of (7�1II
Cell Phone: Lari4ki e:
Email: C� �6� 7 4 g Z177 3 9 �8
M/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 itects)/Eneineer(s):
Business Name:
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
s
Contact Person for any questions regarding this project:
Cell Phone: Land Line:
Email:
Accessory Structure Application Revised January 2021
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ 5,6 (gyp
2. Are there any structures not shown on the plot plan? ❑YES IJ NO Explain:
3. Are there any easements on the property? ❑ YES 1 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 If,for any reason,the building permit application is withdrawn, 30%of the fee is retained by the Town of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.
I have read and agree to the above:
PRINT NAME:
SIGNATURE: C_ DATE: -7 J?
Accessory Structure Application Revised January 2021
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