AST-0764-2021 rim- Office Use Onlv
ACCESSORY STRUCTURE Permit
�- �—' PERMIT APPLICATION
Toxin ofQueensbwy Permit Fee: $ g5 y
742 Bay Road,Queensbury,NY 12804 Invoice#: Lclt)
P:518-761-8256 www.gueensbury.net
Flood Zone? N eviewe
Project Location:
Tax Map ID#: �L c'(� g ` I— q Subdivision Name:
PROJECT INFORMATION:
TYPE: ❑ Residential Commercial, Proposed Use: LTOWNOFQUEEN
021
STRUCTURE: SBURY❑ Boathouse (with or w/o sundeck) ❑ Canopy ❑ Carport ❑ CellTowerDES
❑ Detached Garage (>300 s.f.) ❑ Dock ❑ Gazebo ❑ Pavilion ❑ Pole Barn ❑ Porch ❑ Ramp
❑ Shed <300 s.f. ❑ Solar Panels w o rafter upgrades) CC�NQ�
( ) ( / pg ades) ❑ 3-Season Porch Other:
K
SQUARE FOOTAGE OF STRUCTURE:
1st floor: Zlo SF X Z
2"a floor:
Total square feet:
REVISED
Brief description of scope of project:
Z `(�r�Z 6Ut-F4 S T2vc—rvroc�' / D k' Z 1
Accessory Structure Application Revised January 2021
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$ /E�_!�;_D d
2. Are there any structures not shown on the plot plan? OYES YNO Explain:
3. Are there any easements on the property? ❑ YES XN 0
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 If,for any reason,the building permit application is withdrawn, 30%of the fee is retained by the Town of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 NA
SIGNATURE: DATE: to r t
Accessory Structure Application Revised January 2021
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): �,A�i -6 L - 7S�-,e-
Mailing Address, C/S/Z: //3c3 9 i r? ' �L=Nx t�v�� i W 1
Cell Phone: S/e- / z g-7 Land Line:
Email: W A. f Paop @ cA VA p I L_. cn &&x
• Primary Owner(s):
Name(s): k/V-A i-rta. '> j>-o 10 @'�--r��-�^ , L L c__
Mailing Address, C/S/Z: /i3o
Cell Phone:S(ff Land Line: ---�y-S`-d7�
Email: CK`QOvu-7
S' .CUB
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)/Engineer(s):
Business Name:
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
Contact Person for any questions regarding this project: NO
Cell Phone: Land Line:
Email:
Accessory Structure Application Revised January 2021
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Based on our limited examination,cojjjpl;ance
ywith our Comments Shall not be construeu as
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Reviewed By OCT 14 2021
Date:
TOWN OF QUEENSBURY
BUILDING&CODES
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