AST-000408-2017 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5904 (518)761-8201
Community Development-Building&Codes (518)761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: AST-000408-2017 Date Issued: Thursday, August 31, 2017
This is to certify that work requested to be done as shown by Permit Number AST-000408-2017
has been completed.
Tax Map Number: 239.7-1-29
Location: 155 ASSEMBLY POINT RD
Owner: Richard Kukuk
Applicant: Lake George Docks LLC
This structure may be occupied as a: Dock 478 s.f.
By Order of Town Board
TOWN OF QUEENSBURY
Issuance of this Certificate of Compliance DOES NOT relieve the
property owner of the responsibility for compliance with Site Plan, V
Variance,or other issues and conditions as a result of approvals by the
Director of Building&Code Enforcement
Planning Board or Zoning Board of Appeals.
TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5904 (518)761-8201
Community Development-Building&Codes (518)761-8256
BUILDING PERMIT
Permit Number: AST-000408-2017
Tax Map No: 239.7-1-29
Permission is hereby granted to: Lake George Docks LLC
For property located at: 155 ASSEMBLY POINT RD
In the Town of Queensbury,to construct or place at the above location in accordance with application together
with plot plans and other information hereto filed and approved and in compliance with the NYS Uniform
Building Codes and the Queensbury Zoning Ordinance
Type of Construction
Owner Name: Richard Kukuk Dock $25,000.00
Owner Address: 6 Bradbury ST Total Value $25.000.00
Clifton Park,NY 12065
Contractor or Builders Name/Address Electrical Inspection Agency
Lake George Docks LLC
57 Chapman ST
Ballston Spa,NY 12020
Plans&Specifications
Dock 478 s.f.
$40.00 PERMIT FEE PAID-TIES PERMIT EXPIRES: Tuesday,July 31,2018
(If a longer period is required,an application for an extension must he made to the code Enforcement Officer
of the Town of Queensbury before the ex/jg)ratio,nn date.)
Dated at the Town o ueensb ( / //Mo a 12017
SIGNED BY: /w�✓KI/ /•VJ for the Town of Queensbury.
Director of Building&Code Enforcement
Office Use Only
ACCESSORY STRUCTURE Permit#: �T 1�
PERMIT APPLICATION Permit Fee:$ ^I U
raw,ofQwcnsbury TT
742 Bay Road,Queensbury,NY 12804 Invoice#: ZO Z ip
P:518-761-8256 www.oueensbury.net
Project Location: 1fS D ll v L
Tax Map lD#: 23i U� '— �"
Z Subdivision Name: JUL 0 7 2017
TOWN OF QUEENSBURY
CONTACT INFORMATION: BUIL ING& CODES
• Applicant:
Name(s): Mo cL. � ,►. r Lace �se��ge_ �oc << : LLC
Mailing Address, C/S/Z: S-A: �� IIS bra .v`I 12 02.0
Cell Phone: ( 1�11 ) 2-6o "4 f Land Line:
Email: L. :t_t. FDL. ) „. .:l r �-
Primary Owner(s):
Name(s): k-� k. tc
Mailing Address, C/S/Z: G '(3 cowl o, Sa ( p• - Ga/( AIV (e S
Cell Phone: 57,P s-- -7?-l '4 Land Line:
Email:
• Contractor(s):
Business Name: lex k D "�>ec
Contact Name(s): AA ru e— kA�5
Mailing Address, C/S/Z:4� .fa- �a 1( s 1 sl"� ' ! I ?A 2
Cell Phone: ( SI P q S Land Line:
Email: ✓l n
• Architect(s)/Engineer(s):
Business Name:
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone:�_) Land Line:
Email:
Contact Person for Building& Code Compliance: a-- 6'e' Pr '2
Cell Phone: (5711 11 ) 2(o b — °) 8 1 8 Land Line: �)
Email: ,�t 2,, �r a~ • c-A,
Town of Queensbury Building&Code Enforcement Accessory Structure Application Revised April 2017
PROJECT INFORMATION:
TYPE: Commercial Residential
WORK CLASS:
_Deck, Open Porch _Solar Panels(w/o rafter upgrades) _Carport _Cell Tower
Shed _Pavilion, Pole Barn,Canopy _D _Gazebo
Detached Garage _Boathouse(with or w/o sundeck) _3-Season Porch
—Other(description: 1
SQUARE FOOTAGE OF STRUCTURE:
1st floor:
2n"floor:
Total square feet:
ADDITIONAL PROJECT INFORMATION'
1. Estimated Cost of Construction:$ 25 ow
2. If Commercial project,what is the proposed use:
3. Are there any structures not shown on the plot plan? YES Explain:
4. Are there any easements on the property? YES
DECLARATION:
I. I acknowledge that no construction shall be commenced prior to issuance of a valid permit and will be
completed within a 12 month period.
2. If the work is not completed by the 1 year expiration date the permit may be renewed, subject to fees
and department approval.
3. 1 certify that the application, plans and supporting materials are a true and 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.
4. 1 acknowledge that prior to occupying the facilities proposed I, or my agents, will obtain a certificate of
occupancy.
5. 1 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 rc G w
SIGNATURE: DATE:
Town of Queensbury Building&Code Enforcement Accessory Structure Application Revised April 2017
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--------� JUL 0 7 2017 D
l TOWN OF OUEENSBU Y
1 _ .BUILDING CODES
239.7-1-29 AST-000408-2017 -�
Kukuk, Rich
155 Assembly Point Rd.
Dock 478 s.f. - -
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JUL 7 7
TOWN OF QUEEN:-ti—'
BUILDING 8 '"cY
NEW YORK I Lake George
Sr OF
OPPORTUNITY park Commission
75 Fort George Rd,PO Box 749,Lake George NY 12845 1 518.668.9347 fax 518.668-5001 Info@Igpc.state.nY www.lgpc.stale.ny.us
APPLICATION FOR PERMIT FOR DOCKS, WHARFS AND MOORINGS
THIS APPLICATION IS FOR THE:(check all that apply)
❑ Construction of a New Dock or Wharf ($200) ❑ Placement of a Mooring ($100)
X Modification to an Existing Dock or Wharf($50) ❑ Modification to an Existing Mooring ($50)
❑ Article 15 (Repair, removal, replacement or installation of cribbing as part of wharf construction)
APPLICATION FEE ENCLOSED: r_% (check or money order only)
1. OWNER []Mr. ❑Mrs. ❑Ms. ❑Dc 0 INDIVIDUAL ❑ PARTNERSHIP ❑ ASSOCIATION
❑ CORPORATION ❑ MUNICIPALITY ❑ AGENCY
NAME K,iY-,kC ?,veort t- 3) EMAIL 9.r„x \t,,1tOL R� rM
CONTACT PERSON IF OWNER IS NOT AN INDIVIDUAL C� t+�t/ l'�✓<<
MAILING ADDRESS {,"
CITY STATE L I ZIP CODE PHON 5+4
"If this is an a sociation or if other parties have deeded or contractual access to this lakefront,please complete Addendum A
2. AGENT 0 NONE ❑PRESIDENT OR CEO ❑LLC MEMBER ❑ATTORNEY ❑CONSULTANT I)tONTACT PERSON
NAME 1 EMAIL (Y u r a, Yjv; r Z A
COMPANY L Le Pj o O Imo! C
MAILING ADDRESS
CITY 5 ^ STATE N ZIP CODE 11,u Z' PHONE
3. CONTRACTOR (Ir known)
NAME S r( t w�, EMAIL
COMPANY
MAILING ADDRESS
CITY STATE ZIP CODE PHONE
4:-PROJECT LOCATION
TOWN [ITICONDEROGA 13 DRESDEN SECTjOiN G BLOCK LOTZ
❑ FORT ANN ❑ HAGUE S� 1
❑ LAKE GEORGE ❑ PUTNAM STREET
EY'QUEENSBURY 0 BOLTON ty
LAKE FRONXGE feet NUMBER OF WHARFS AND MOORINGS CURRENTLY ON PROPERTY
according to qrTax Map ❑ Survey(attach copy) 1 DOCKS MOORINGS (Please fill in a number or 0 for each)
DOES LAKEFRONT CONTAIN WETLANDS? ❑ Yes d No STREAMS?0 Yes YA No(If yes,show on project plans)
5. PROJECT DESCRIPTION
PROJECT DESCRIPTION ' ' 1w tt �k s Z U //�i�,_A n^ L
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U:ISHAREDILGPC Paximm-Environmental Pemfds1FonnslDocks&Moorimgslwharfmoompd 10111116 Page 1 Of
NEW YORK I Lake George
STATE OF
OPPORTUNIN_ Park Commission
75 Fort George Road,P.O.Box 749,Lake George,NY 12845 1 518.668.9347 Fax:518.668.5001 1 w Agpc.slale.nyms info@Igpc.state.ny.US
NOTICE OF AVAILABILITY FOR REVIEW
Date: June 23, 2017
TO INTERESTED PARTIES: Comments Due: July 08,2017
This notice is being sent to allow you an opportunity to comment on the proposed project below. Written comments
must be received by the"comments due" date above and should detail specific reasons for your interest,support
or opposition.
If you have no comments you do not need to return this form.
Return this form and any comments by email or mail to the above address,the analyst assigned is:
Molly Gallagher, molly@lgpc.state.ny.us
Applicant: Richard Kukuk Application: 5234-30-17
Kukuk Property Trust Type: DM Minor
Rill Box 1849 Wharf Modification
Lake George, NY 12845
Parcel#: 239.07-1-29
Project Location: 155 Assembly Point Town of Queensbury
Project Description:
Remove an existing wharf and construct a 32'long, 26'wide, U-shaped wharf and open-sided,rock-filled
Umber cribs to be used as support for wharfs in accordance with plans attached
State Environmental Quality Review Lead Agency: None Designated
SEQR Determination: 1 -Type II Action, no further review under SEQR
Comments: ❑No Comments ❑Comments below or attached
EC E III
JEE
UN 2 7 2017 D
TOWN F QUEENSBU1
f3UiL INS&CODES
cc: APA r b ryr;-0 '
Town of Queensbury Comments prepared by: 1
Sarah &Bruce Brown Address:
Frederick&Joliene Boenau
E-mail:
Telephone: Date:
NEWYORK I Lake George
SrAI OF
° -MOF"n Park Commission RECEIVED
75 Fort George Rd,PO Boz 749,Lake George NY 12845 1518.666.9347 fax 518.668-50011 Info@Igpc.state.ny www:fg06.'state;6y.67
APPLICATION FOR PERMIT FOR DOCKS, WHARFS AN6Y14A66kffiGS''1,A1SS10N
THIS APPLICATION IS FOR THE:(check all that apply)
❑ Construction of a New Dock or Wharf ($200) ❑ Placement of a Mooring ($100)
X Modification to an Existing Dock or Wharf($50) ❑ Modification to an Existing Mooring ($50)
❑ Article 15 (Repair, removal, replacement or installation of cribbing as part of wharf construction)
APPLICATION FEE ENCLOSED: �—(check or money order only)
1. OWNER ❑Mr. ❑Mrs. ❑Ms. ❑Dr. ❑ INDIVIDUAL ❑ PARTNERSHIP ❑ ASSOCIATION
y —T' ❑ CORPORATION ❑ MUNICIPALITY El AGENCY
1
NAME I<.f Yv t0 ?N(7 V r`l., !' V.3 E EMAIL Q.+. \t (t 1Kili\ AQ
CONTACT PERSON IF OWNER-IS NOT AN INDIVIDUAL <V t<V
MAILING ADDRESS .. y�C. I C,
CITY`SSTATE ZIP CODE PHON 5a $A , a dJ
"If this is an association or if other parties have deeded or contractual access to this lakefront,please complete Addendum A
2. AGENT ❑NONE ❑PRESIDENT OR CEO ❑LLC MEMBER ❑ATTORNEY ❑CONSULTANT btONTACT PERSON
NAME EMAIL
COMPANY Lt i,p pNr a 0,L_1 I C
MAILING ADDRESS G(, tq At." �
CITY / S ^ STATE�(/ ZIP CODE ! u L.a PHONE Q C7
3. CONTRACTOR (If known)
NAME S EMAIL
COMPANY
MAILING ADDRESS
CITY STATE ZIP CODE PHONE
.d_..PROJECT.LOCATION - -- --
TOWN ❑ TICONDEROGA ❑ DRESDEN SECTIO O BLOCK ( LOTz
❑ FORT ANN ❑ HAGUE
❑ LAKE GEORGE ❑ PUTNAM STREET ,I
®'QUEENSBURY ❑ BOLTON 5 r•t.rv1 ` t1r !` tL+ lei
LAKE FRONT4GE feet NUMBER OF WHARFS AND MOORINGS CURRENTLY ON PROPERTY
ecoonling to 9111rax Map ❑ Survey(attach copy) I DOCKS MOORINGS (Please fill in a number or 0 for each)
DOES LAKEFRONT CONTAIN WETLANDS? o Yes 4d No STREAMS?❑Yes 0 No(If yes,show on project plans)
5. PROJECT DESCRIPTION ��jj
PROJECT DESCRIPTION p�� p )q Lt x:S I U dp e C I e L
W"At i nAd. MftMe ENt�1e
to E A �0 ' `'b VILC 1' 5, ' At (,�.tr d tot,tfiz 5
U!\SHAREDILGPC Program-Environmental Permils\Form0ocks&MoofingsAwharfmoomfid 10/11116 Page 1 of
PROPOSED USE RESIDENTIAL 0 COMMERCIAL 0 ASSOCIATION 0 PUBLIC
TYPE OF CONSTRUCTION 0 STAKE @CRIB 0 PILE 0 ARTICULATING 0 OTHER
0 CANOPIED BOATLIFT 0 UN-CANOPIED BOATLIFT 0 PWC LIFT (include manufacturer specification sheet for all Ift)
PROPOSED STARTING DATE 2-w PROPOSED COMPLETION DATE z
IS ANY PORTION OF THIS ACTIVITY FOR WHICH A PERMIT IS SOUGHT NOW BEGUN OR COMPLETED?
0 Yes 044o (if yes,please explain)
IF COMMERCIAL,IS THE FACILITY AND ITS ASSOCIATED LAND USES IN COMPLIANCE WITH APPLICABLE
PROVISIONS OF STATE AND LOCAL LAWS,ORDINANCES,RULES AND REGULATIONS?
0 Yes 0 No(it no,please explain)
6. ADJOINING LAKEFRONT PROPERTY OWNERS (available from your town or county real property dept)
NAME '. t't..}.. t T ?.:. ie,A", NAME ('o✓tv p
TAX MAP# ,^f� , '"7 ?.. �? ➢ TAX MAP# 4` !?.2Y'L',�,�.L
MAILING MAILING
ADDRESS ADDRESS
7. CERTIFICATION
I hereby affirm that the information on this form and all attachments submitted herewith is true to the best of my
knowledge and belief.
I hereby consent to the Commission staff working directly with my agent,as designated on page 1 of this forth,during
the review of this application.
During the processing of this application Lake George Park Commission(LGPC)personnel or their assigns may need
to visit this site to inspect,measure, make drawings and/or take photographs. I hereby agree that LGPC staff or their
assigns may enter upon and pass through this property in order to Inspect the project site or facility,without prior
notice,between the hours of 8:00 a.m.and 5:00 p.m.,Monday through Friday,while the application is pending. In the
event that the project site or facility is posted with any form of"posted"or"keep out"notices,or fenced in with an
unlocked gate,this permission authorizes LGPC staff or their assigns to disregard such notices or unlocked gates at
the time of inspection.
As a condition to the issuance of a permit,the applicant accepts full legal responsibility for all damage,direct and
Indirect,or whatever nature,and by whomever suffered,arising out of the project described herein and agrees to
Indemnify and save harmless the State from suits,actions,damages and costs of every name and description
resulting from the said project.
SIGNATU OF OWNER/(�N�ote title T igning for a corporation or association) DATE
h" / Tusfee - 6-(�-ZGl7
PLEASE COMPLETE ALL ITEMS ABOVE AND INCLUDE WITH THIS FORM:
0 Application fee
0 Site location map
0 Copy of survey if available
0 Photographs of existing dock(for dock modification applications)
l7 Project plans on 8%X 11 size paper-PLANS MUST BE TO SCALE&SHOW ENTIRE LAKEFRONT
l7 Short Environmental Assessment Form if project involves
• A new Association or Commercial dock or mooring
• More than one residential dock or mooring
• A dock or mooring to be located in a wetland,fish spawning area,an area of significant
wildlife habitat,or an area of unique scenic,historic or natural significance
0 Addendum A Co-owner Signature Page(if lakefront Is jointly or commonly owned)
0 Addendum 8 Parties with deeded or contractual access to this lakefront
Failure to include any one of the required Items will result in an Incomplete notice and delay In processing your application. Permits
and appr4vals maybe required from other agencies and municipalities
WSHAREDILGPC Program.Envimnmontal Pe mlWFormskDock4&Mooringslwharfmoo.wpd i0r11H6 Page 2 of 2
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Lf✓.E GEORGE PARKCOMA -KA''
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LAKE GEORGE PARK CO^MNSSION