AST-0530-2023 Office Use Only
ACCESSORY STRUCTURE ._.w.. Permit#: 0630-•�a3
Town of Queensbury P !LE P r1 P T + I r- 1,\ Permit Fee:J $ /4
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742 Bay Road,Queensbury,NY 12804 A UG 2 p 2�23 i Invoice#:
l7 v
P:518-761-8256 www. ueensbur a
Flood Zone? Y Reviewed By:Cl/
TOWN OF QUEENSBURY
BUILDING ey.CODES
Project Location: 67 a1Iem6 i , Oueenthay,A
Tax Map ID#: : - I �f t Subdivision Name:
PROJECT INFORMATION:
TYPE: Residential ❑ Commercial, Proposed Use:
STRUCTURE:
❑ Boathouse(with or w/o sundeck) ❑ Canopy ❑ Carport ❑ Cell Tower L/J"Deck
❑ Detached Garage (>300 s.f.) ❑ Dock ❑ Gazebo 1=1 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:
2nd floor:
•
Total square feet: S f
Brief description of scope of project: Ada 1e..C. �C 7 a .Favt,j
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Accessory Structure Application Revised November 2022
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$ 0i4a
2. Are there any structures not shown on the plot plan? ❑ YES VO Explain:
3. Are there any easements on the property? El YES LvJ'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 If,for any reason,the building permit application is withdrawn, 30%of the fee is retained by the Town of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: , V, /Ik
SIGNATURE: I//� DATE: 04/4013
74
Accessory Structure Application Revised November 2022
I
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
i /„ZG
. JO �ok • �`��Name(s): LO ,�' /J��
Mailing Address, C/S :�P2i1 ,�' �� , W'1eeI'IS�a� /19y ziervi
Cell Phone: 5/8-3Z/- 5337/ * 74-and Line: — ✓✓,`
Email: � SACt. !?d� da !fug Coz vile.hotyhaa/Pyrit,O.C.44,
• Priv�Owner )
Name(s): E U' '��L
Mailing Address, C /Z: 9 i" �� &{een5f/y, /W `o?f
Cell Phone: F/f�Jz/-g337/ 7 ''075 Land Line: -
Email: /h f/'/./JkI L I9IK�t/ZCam )e.hoyiti.m/®L/�,ILD�.CdYX_
U
Check if all work will be Yproperty bowner only
performed
• 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: (%e Arlfk ix .
Cell Phone: 5//- 1 -49o75 Land Line: --
Email: dm. hAu f g J oj41Jt12 . G -
Accessory Structure Application Revised November 2022
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11 `4 .X & L!S / TOWN OFQUEEtJS
BUILDING D;-�ARTMERT
Based on our limite
�/ Ai m,'h,V +n ` --I S with our comments st�k��mination,compliance
pe.._
_ �„�., eA e,,, �� ;�. indicatin c G, nct be construed as full comp!anc 1ittrat��S�u Idingt�modes o
fi o o vs t New York State.
e s i f..; e- 5.7--r.,r.., -cc s
TOWN OF QUEENSBURY
ail' DING c& CODES DEPT.
V E 3 Date: i1,
\ _ G 2 8 2023 :, \\ ,.
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303.16-1-11 AST-0530-2023
Hougham, Mary Lou
69 Queensbury Ave 251 s.f.
Post construction deck
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