AST-0359-2023 e
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Office Use Only
l� ACCESSORY STRUCTURE Permit#:
P �;�T� •$
Town of ueens6u D Permit Fee:
742 Bay Road,Queensbury,NY 12804 Invoice#:
P:518-761-8256 www. ueensbur .n t JUN.2 ?�''' i ,
Flood Zone? Y �I Reviewed By610A0
TOWN OF OUEENSBURY
BUILDING&CODES
Project Location: 3 s���^/?�fxN ✓-�
Tax Map ID#: 3 c)2 r l D '`�''' ]� Subdivision Name:
PROJECT INFORMATION:
TYPE: 5� 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 ❑ Other:
SQUARE FOOTAGE OFF STRUCTURE:
1st floor:
2nd floor:
Total square feet:. �d®
Brief description of scope of project: C d I d Si Or (Bc-lh, C ru$,� rX k`
2(2 y 2 5 s� r µ t r 2
Accessory Structure Application Revised November 2022
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ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ /o% G 3 •3 0
2. Are there any structures not shown on the plot plan? ❑ YES f7 NO. Explain:
3. Are there any easements on the property? C9,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 If,for any reason,the building permit application is withdrawn, 30%of the fee is retained by the Town of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 certificate of occupancy.
have read and agree to the above:
PRINT NAME:
SIGNATURE: DATE: G 2 2 3
Accessory Structure Application Revised November 2022
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• A licant•
Name(s): Ivey) vl% ik4 5
Mailing Address, C/S/Z: 03 S -,e r iuH ✓
Cell Phone: S /6- 7e-1G/ T537 Land Line:
Email: Q Pk;
• Primary Owner(s):
Name(s):
Mailing Address, C/S/Z: 233 A
Cell Phone: -Pr - 2cf Y-9'5.)7� Land Line:
Email: '��ti��r'!�S 92 6 c'e'ri-I
❑ 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): yc in i e� fly rkc LL
Contractor Trade: Pi-c --PvA--,c-4,Et lfle 4-�a ( 5"� v'ue t are 5
Mailing Address, C/S/Z: fZ 5�' CU&J-e A7 CO. k boeo ,.AX C 2 :9 /2 q
Cell Phone: Land Line: 93C ' 367-81372
Email: Sa-wt td 6&4;lo 14l! sx co
"Workers' Comp documentation_ must be submitted with this application**
• Arch itect(s)/Engineer(s):
Business Name: M 00('e a,j a55 oc i u�eS
Contact Name(s): ,_- H e M D U1,z
Mailing Address, C/S/Z: !�fU t 5,rAa�,1 5'4ree'�. tAwr'x 170 oc«4"Xiry,�tlC, 7-76
Cell Phone: 33 6- -719-2 O 2 0 Land Line:
Email: reQru-15}SO = 'ei4 J) ihee;' (Vlg
Contact Person for any questions regarding this project: �a �'A a ® 01'e
Cell Phone: Land Line: _ 3 G 3 6 k- �2:5'?
Email: ct,►'h 'P" D C U !�
Accessory Structure Application Revised November 2022