AST-0594-2022 -t
A )
Office Use Only
ACCESSORY STRUCTURE Permit#: � -O - 20
Tam of Queen ry PERMIT APPLICATION Permit Fee:$ &3
742 Bay Road,Queensbury,NY 12804 Invoice#: r--4-
P:518-761-8256 www.queensbury.net Flood Zone? Y Reviewed By6"1
Project Location: b 5 //Z 10 11 S ,
Tax Map ID#: JD9 /b"I- 5:5 Subdivision Name:
PROJECT INFORMATION:
TYPE: XI Residential ❑ Commercial, Proposed Use:
STRUCTURE:
❑ Boathouse (with or w/o sundeck) ❑ Canopy E Carport ❑ Cell Tower ❑ Deck
❑ Detached Garage (>300 s.f.) E Dock ❑ Gazebo ❑ Pavilion ❑ Pole Barn ❑ Porch ❑ Ramp
Shed (<300 s.f.) ❑ Solar Panels (w/o rafter upgrades) ❑ 3-Season Porch ❑ Other:
y��7- SQUARE FOOTAGE OF STRUCTURE:
E C 0 v 1st floor: O
SEP 2 3 2022 E )
1 g
2nd floor:
.
TOWN
OF QUEENSBURY Total square feet: Z 86
BUILDING&CODES
Brief description of scope of project: 5be(\ CSC 5 e Jesse, i a
Accessory Structure Application Revised June 2022
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$ ( /(jCjC),
2. Are there any structures not shown on the plot plan? El YES gi NO Explain:
3. Are there any easements on the property? r3 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 If,for any reason,the building permit application is withdrawn, 30%of the fee is retained by the Town of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: 2%.\ ser
SIGNATURE: d. DATE: I--Ze -2,2
Accessory Structure Application Revised June 2022
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CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant: ' I
Name(s): Sys'-kit Vl -P-.1 w e c
Mailing Address, C/S/Z: 6 S '/Z V►1 1-1 54 ( es_v 5 \oufv /Uy 128vy
Cell Phone: ri$ 796 /5-1'( Land Line:
Email: b 0` 3 Cs
• Primary Owner(s):
Name(s): ► cl/V_Q.
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
El 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): -- VVL.
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:
Contact Person for any questions regarding this project: . 1 +'
.17
Cell Phone: Land Line: p'f
Email:
Accessory Structure Application Revised June 2022
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