AST-0458-2022 �4:,
Office Use Only
ACCESSORY STRUCTURE Permit#: NZV n5b•?.�L2
PERMIT APPLICATION t'
Town ofQyee� Permit Fee:$
742 Bay Road,Queensbury,NY 12804 Invoice#: vZ
P:518-761-8256 www.gueensbury.net Flood Zone? Y Reviewed BydAA0
Project Location: '441 1mklw4 M40' Fd' Lake. 6&r5t.. N , 12W VAl � 1 I
Tax Map ID#: ' 4r— I `) I Subdivision Name: NIA,
PROJECT INFORMATION:
TYPE: Lir Residential ❑ Commercial, Pra ee"r see 0
STRUCTURE:
TOw�!OF UEENSBURY
❑ Boathouse(with or w/o sundeck) ❑ Canopy ❑ Carp ``rt BUILDIP �ei); u�e$ ❑ Deck
t�
❑ Detached Garage(>300 s.f.) ❑ Dock ❑ Gazebo ❑ Pavilion ❑ Pole Barn —`❑ Porch` ❑ Ramp
❑ Shed (<300 s.f.) El Solar Panels(w/o rafter upgrades) El 3-Season Porch L/Other:
SQUARE FOOTAGE OF STRUCTURE:
1st floor: )A-
2 nd floor: IA-
Total square feet: N I A-
Brief description of scope of project: R""V&( AV%d rerlatQQ.IZCQ.A+ of 4cm. 400 SvI0�01r�'
C6 10Y01ns &x(P Pons) ., sv`o&4- �eawl C(-Auu*rn) , eu&at am!j S q - iaa-
IS vlterw�� 4D mmove. New Ar4l'K�Ate61- aS ► wdeA.
No c�ancx- Rio &4pn n f cy Pf&a CHwt.�S .
Accessory Structure Application Revised March 2022
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$ I��ocb- W
2. Are there any structures not shown on the plot plan? ❑ YES R 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 If,for any reason;the building permit application is withdrawn, 30%of the fee is retained by the Town of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 atrue 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: DATE:
Accessary Structure Application Revised March 2022
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant: n
Name(s): DI/�he✓h �v�ldevs (,(� ne✓S
E � +� � 12�Sq
Mailing Address, C/S/Z: 33 AI fZOY*K r
Cell Phone: SR'"76Kv WA+ Land Line:
Email: VIdevinoQKVr44wnb1J-'C0M
• Primary Owners :
Name(s): &-W APA Uni,�, 11 � ply
Mailing Address, C/S/Z: qql
Cell Phon : rj(� Jrt�,�_� t� Land Line: --
Email: �4e
❑ 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): �Jpr-fkpXn &ll. 99
&S
Contractor Trade: &�,u.�ksr' N`� )2
Mailing Address, C/S/Z:'*;3 A+M0 I w.4 ?()4w &"W
Cell Phone:z%r 7% (e(A+ .Land Line:
.Email )gde�v40 A0rJ4J4err1 C01M
**Workers Comp documentation must be submitted with this application**
• Architect(s)/Engineer(s):
Business Name: .aVtKa r1 Arntak Ca
Contact Name(s): Cla It—
Mailing Address, C/S/Z: W Sh I 4cn
Cell Phone: -Land Line:
Email 5e0anav&�46,00.com
Contact Person for any questions regarding thisproject: A '6c �aS �en►� �dfn ���.�z�
1v
Cell Phone: 5u- 7% (ew Land Line: �-®-
Email
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Accessory Structure Application Revised March 2022