AST-0598-2021 A
rha Office Use Only
J% ACCESSORY STRUCTURE Permit#:
Town of Queensbury PERMIT APPLICATION Permit Fee:$ 200
742 Bay Road,Queensbury,NY 12804 �� Invoice#:40 b
P:518-761-8256 www.gueensburV.net —
Do Q'��.!� Flood Zone? Y Reviewed B .
Project Location:
Tax Map ID#: 2j.—� — 1p(� Subdivision Name:
- PROJECT INFORMATION:
TYPE: `C 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
❑ Shed(<300 s.f:) ❑ Solar Panels(w/o rafter upgrades) ❑ 3-Season Porch —
D CLEOW
SQUARE.FOOTAGE OF STRUCTURE:
AUG 13 2021
G=stfloor.
TOWN OF QUEENSBURY
2"d floor: BUILDING& CODES
Total square feet: ����
,Brief description of scope of project: +- -J--�tl
-�
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"n V
Accessory Structure'Application Revised January 2021
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$
2. Are there any structures not shown on the plot plan? ❑YES �00 Explain:
3. Are there any easements on the property? ❑ YES R 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 If,for any reason,the building permit application is withdrawn,30%of the fee is retained by the Town of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
construct d facilities prior to issua ce of a certificate of occu ncy.
I have read and agree to the above:
PRINT NAME:SIGNATURE: �/�/ .� _(4" 11 � ��/� ,ic,c_,.ay�, DATE: Zz
Accessory Structure Application Revised January 2021
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): C5—"
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
• Primary Owner(s):
Name(s): '16pr%n,- mi. A-esevC�
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)Aneineer(s):
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: Y
r
Accessory Structure Application Revised January 2021
'Rispector'"s No: :.
COMMONWEALTH ELECTRICAL INSPECTION.SERVICE,:INC_ " "
(Consulting and Fire-Inspection Services)
(Incorporated in the states_of New York; Pennsylvania, and West Virginia)
Desiring Certificate of Approval,application is-made for•inspection.of electrical installation,in the premises described belovi+: .On
demand,.applicant agrees to pay for,inspection service in accord with schedule of charges.
Owner:' c l a �"lh, ��.art .61�, A.
Type Building:Dwelling t �qer(pl se specify):
Job Locatio 4 y'; i. ..; City: State:"
County V P v-, Permit From: Permit# f
Swimming Pooh, Inground Aboveground: Bonding Date: r'
Wor New Additional Bldg., New r; New `'�..; , Old Ready for Inspection
.APPlicants Signature: . � �
: License#:
Please Print Name: 1 Phone#:
Applicants Address:" _ -•, #r J Name.of Utility;
City:. _ �/ . . 'Office.To Be
\/ .�' ¢ State: I ,� C f I
Noti
: . p:: fied: Job.#:
Zi "
SPACE BELOW FOR USE.OF INSPECTORS ONLY
Switches Water Heater. Service Equipment Other list below E
Receptacles : Paddle:Fan/Light control. Service Equipment
GFCI Rece o t Paddle Fan : Panel
AMP Rece t Paddle Fan/Li ht . Dryer Rec
J:«= Lights Ventfan Washer Rec
,.
Lights . Air Conditioner,' Dishwasher Rec
'Smoke Detectors_. AFCI Breaker Microwave Rec
Smoke/CO Detectors . GFCI Breaker Gafbage Disp Rec
AFCl/GFCI Breakers Refrigerator Receptacle,
Additional apparatus for certificate:-(Not listed above) Inspector Job Notes: . ,
-installed By(if other than applicant):
` OFFICE USE ONLY.
Extra tri dates ` Ins ection Fee$ .J
Date Received: Service Date: 1 CASH
Certificate No-R.W.Date: ' - 2 Check No.
Final Date: -3 Invoice
Certificate Needed?. :' ' ,4 CC
Date.Sent:
Inspectorsign in'
Yes_�fup next s ace. ( '�;, 1
Please print name Inspector: `�`. �il�.iA.�
.Original Progress Final
THIS APPLICATION EXPIRES,ONE.YEAR FROM DATE " MAKE ALL FEES PAYABLE TO C.E.I.S.INC::
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TOWN OF QUEENSBU Yam'; cf '
BUILDING DEPARTMEf�T---------_-��-------•- r •- �.- ff �v
Based on our limited examination,compliance 1 2- -- 16. 0'r
with our comments shall not be construed as �t
indicating the plans and specifications are in (Y
full compliance with the Building Codes of
New York State. N Ze �€7 -
TOWN OF QUEENSBURY
BUILDING & COD PEPT.
Reviewed By: yx T; sl�! r��S- -;� c
Date: (cP
-- F I L
278.-1_60 AST 0598-2021 f
Stranahan, Skip --
1343 Bay Rd
Detached Garage
416 s.f. ,
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