AST-0148-2023 ii
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Office Use Only
ACCESSORY STRUCTURE Permit#: Pr51-- 9 litcL--) -2025
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Town of CZneensbury I 112 PePLICATIRNE ,;\ Permit Fee:$ I tc) —
] Invoice#:
742 Bay Road,Queensbury,NY 1280 ''.
L i PR 0 2h"" '
P:518-761-8256 wwW.aueensburvaie n, If ......!.:..) ,I
1 Flood Zone? Y 0 Reviewed By: fiq‘
TOWN OF 7::5:."5:1:53-ay
• BUILDING 8., CODES I CE
Project Location: SlOki e. Cctle.- .
Tax Map ID#: a6 7 , 1 - Te. : Subdivision Name: 5-1-wie&i6d-e_ AAAttor.
PROJECT INFORMATION:
-TYPE: ig Residential CI Commercial, Proposed Use:
STRUCTURE: •
E Boathouse(with or w/o sundeck)- 111 Canopy El Carport 0 Cell Tower Xl Deck
- El Detached Garage (>300 s.f.) 111 Dock E.Gazebo El Pavilion - CI Pole Barn , Porch El Ramp
111 Shed (<300 s.f.) El Solar Panels (w/o rafter upgrades) 111 3-Season Porch CI Other: c.,c("rel eh POre-4. --i-
e vtJ7
SQUARE FOOTAGE OF STRUCTURE:
. .
1st floor: I 9(
2nd floor: -
Total square feet: /9'tJ
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I Y 1-v14 -
Brief description of scope of project: inyay
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Accessory Structure Application Revised November 2022
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ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$ l?_Q() e
2. Are there any structures not shown on the plot plan? El YES C 'NO Explain:
3. Are there any easements on the property? ❑ YES 'NO
DECLARATION:
1. I 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 If,for any reason,the building permit application is withdrawn,30%of the fee is retained by the Town of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. If the work is not completed by the 1 year expiration date the permit may be renewed, subject to fees
and department approval.
4. I 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. I acknowledge that prior to occupying the facilities proposed I, or, my agents, will obtain a certificate of
occupancy.
6. I 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: Dkil\e/1
SIGNATURE: DATE:
Accessory Structure Application Revised November 2022
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant: K
Name(s): Ij an;e l D t l L
Mailing Address, C/S/Z:_C C.v 441 2TVh apt d r J- k 1—ec,r� e /l� ( 1214f
Cell Phone: ,�/ / y Land Line: S 8" g
� a � � r �6 �i��r
Email: f)eh7)? 6 rj(ci O •
• Primary Own9r(s): 4
Name(s): Oiu't ei( r,)-e f1F'
4
Mailing Address, C/S/Z: Si vi GAS ato Ve- - MUY� m0Q.-r C
Cell Phone: Land Line: Sck,(-C&7cr rS
Email: 1�
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**
• Architect(s)/Engineer(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: '1� 6tvi(mil fi d`�tc
Cell Phone: c('g12 — q(igt/ Land Line:
Email: Oe-O7» e VG.✓►Ao- 1'.
Accessory Structure Application Revised November 2022
91
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