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AST-0631-2023 Office Use Only
, 1 ACCESSORY STRUCTURE Permit#: —0I0,6 l 292�
PERMIT APPLICATION 1 p Ob —
Trnvn of Queensbury Permit Fee:$
742 Bay Road,Queensbury,NY 12804 Invoice#: (c2-C-Q-
P:518-761-8256 www.aueensbury.net Flood Zone? Y viewe
Project Location: 2 0 R iS t �cJ�, Qu.e.1vr
Tax Map ID#: 253"1'' I Subdivision Name:
PROJECT INFORMATION:
TYPE: 0 Residential OD Commercial,Proposed Use: S/10041 15 ,irv:50
STRUCTURE:
❑ Boathouse(with or w/o sundeck) El Canopy ❑ Carport 0 Cell Tower 0 Deck
❑ Detached Garage(>300 s.f.) El Dock ❑ Gazebo 0 Pavilion ❑ Pole Barn ❑Porch 0 Ramp
❑Shed(<300 s.f.) ❑tSolar Panels(w/o rafter upgrades) 0 3-Season Porch 0 Other:
SQUARE FOOTAGE OF STRUCTURE:
1st floor: Ag10 'C 12 A 880 Sy FT
2nd floor:
Total square feet 2.ggv Si r T
Brief description of scope of project: K e/i'i v e 39450 S'r Fr Ca n ,0 y -ne
Cpn3.47,&&4 �. ,/iew 28-0 5.3 P? Cotiopy.
Accessory Structure Application Revised November 2022
•
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ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$ /8'6 000
2. Are there any structures not shown on the plot plan? ❑ YES St NO Explain:
3. Are there any easements on the property? ❑ YES I 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 If,for any reason,the building permit application is withdrawn,30%of the fee is retained by the Town of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: ietT/t � C F1,04Air>
SIGNATURE: DATE: ?/2 9/23
Accessory Structure Application Revised November 2022
•
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): PAT) ICK
Mailing Address, C/S/Z: 79 Sunsc'1' I r -'L1 Q iee#Sbw7 M Y /2$d74/
Cell Phone: 5)&- 2(o0-�2.L cii-1 Land Line: 51�-79'1-• 2-CS
Email: ?belan12o4 rL Q,4L, Carp,
• Primary.Owner(s):
Name(s): Dow ha 'c 5Ay IA.3 4 Game aik 1'
Mailing Address, C/S/Z: `)?O, J3o 4'ZG.S, aM.r ,Sbw7,./c/`/ /Levy
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): T
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: f uc,,,SKi• t u- Arc. h)-1-ef 4-S
Contact Name(s): ETI A,✓
Mailing Address, C/S/Z: /3'1 Doc 4-irG -i+aczj Ary /zto9
Cell Phone: Land Line: ne-74// - a2rvb
Email: e p ha.11Q NYC.4P, cF. C "^
Contact Person for any questions regarding this project: ('j4Tr1 G 56(... iv
Cell Phone: 5'U- Land Line: S/8'7` Z.-2c3U
Email: bedavit dGY- coo.
Accessory Structure Application Revised November 2022
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