AST-0212-2023 Office Use Only
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ACCESSORY STRUCTURE Permit#: f T- 6212." 20 z�
= PERMIT APPLICATION
Town ofQueensbury Permit Fee:$ 12—‘1O
742 Bay Road,Queensbury,NY 12804 Invoice#: (120 s
P:518-761-8256 www.queensburv.net Flood Zone? Y Reviewed
Project Location: \\52,4`e 5 -cot L- k e.
Tax Map ID#: 30t ,
-a 0 ` — 39, Subdivision Name: 6--
PROJECT10) C E 0 W7 E
INFORMATION:
ifil 9AY 0 3 202:3 ij
TYPE: Residential ElCommercial, Proposed Use: _
TOWtj OF QUEENSBURV
BUILDING& CODES
STRUCTURE:
❑ Boathouse(with or w/o sundeck) ❑ Canopy Cl Carport ❑ Cell Tower Deck
❑ Detached Garage (>300 s.f.) ❑ Dock El Gazebo ❑ Pavilion ❑ Pole Barn ❑ Porch ❑ Ramp
❑ Shed (<300 s.f.) ❑ Solar Panels(w/o rafter upgrades) ❑ 3-Season Porch ❑ Other:
SQUARE FOOTAGE OF STRUCTURE:
1st floor: Q T k
2nd floor:
Total square feet: $ a -C}a
Brief description of scope of project: T e\o.v\ k 0 1 tC 1C o COr►AtGt
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ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $
po0
2. Are there any structures not shown on the plot plan? ❑ YES 'W NO Explain:
3. Are there any easements on the property? ❑ YES 'X(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 If,for any reason,the building permit application is withdrawn,30%of the fee is retained by the Town of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 thework 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:
SIGNATURE: %4L XitzX DATE: — 3
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s):
Mailing Address, C/S/Z: 1-7 t'Icfes-VorrA L•,nt ! Q�nLch 5 �rj,,,�v N."(,
Cell Phone: S 1$ -y$Q -S 13 7 Land Line:
Email: 1'tw• s\ c\ @
• Primary Owner(s):
Name(s): Sot v-v,�
Mailing Address, C/S/Z: - - -
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):
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: ;�� tc_11, •
Cell Phone: Land Line: KA
Email:
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