AST-0595-2019Office Use Only
ACCESSORY STRUCTURE
Perm i,
PERMIT APPLICATION
Tiwan r.,i' p spa �,saa'° rmit Fee: u
742 Bay Road, Queensbury, NY 12804
Invoice
�2nqm net
Tax p I 2 ,14-1-6 Subdivision Name:SEP
CONTACTINFORMATION:
"
TOWN OF QUEENSS Y
I a tM BUIL i a � �
rn s). Philip Birmin h rn�
Mailing Address, . @ Pltzeral �dnd r ��
Ce
ll ()- Land Line;
Email
Primary nr
Mai Address, n
II Phone: ® Land Line.
Email'.
if all work will be performedhomeowner
Contractj Workers" Comp documentation must be submittedwith i application
Contact a(s).
Co, ntr t r Trade
Mailing Address, ,/.
11 Phonea Land Line;
Ernaila
*List all a d d it o n acoIntractor n the f this form
Business Name:
Contact J (s),
ailing Address, a
II Phone: Land Line.
Email.
Contact Person for Building & Code Compliance. Owner
II Phone. Land Line:
Piail,
PROJECT INFORMATION:
TYPE: P_ Commercial M, Residential
WORK CLASS:
El Deck, Open Porch Solar Panels (w/o, rafter upgrades)
Carport 7 Cell Tower
CI Shed Pavilion, Pole Barn, Canopy OKI Dock Gazebo
0 Detached arage 7 Boathouse (with or w/o sondeck) 3-Seacan Porch
Other (clescrfption-
SQUARE FOOTAGE OF STRUCTURE,
1st floor--, 487,6
2"'J floor. -
Total sq u.a re feet, 4 87s 6
A
DDI QNATK (P13QJEQTINf-,,
1, Estimated Cost of Construction. $
2. If Commercial project, what is the proposed use:
3. Are there any structures not shown on, the plot plain? YES, NO Explaln:
4. Are there any easements on the property? D' YES NO
OFQLARATION"
I [ acknowledge that no construction shall be, corornenced prior to issuanof a valid permit and will be
completed within a 12 rnonth period,
2. If thework is not completed by the I year expiration date the Permit may be reinewed, subject to fees
and department approval.
3, 1 certify that the appl icatfon, plans and supporting materials are a true and I complete staternent 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 1, or my agents, will, obtain a certificate of
occupancy.
5, 1 also understand that ]/we are required to Provide arras -built survey by a, licensed land surveyor of all newly
constructed facilities prior to issuance of a certificate of occupancV,
I have read and agree to the above:
PRINT NAMF� Philip Birmingham
SIGNATURE: DATE _99 193J 01�
Arf
Fvbrvary 2019
'UNAllTHOftiZED ALTERATION OR ADDITION TO A SURVEY
Map
of a Survey made for
MAP BEARING :A LICENSED LAND SURVEYORS SEAL IS A
VIOLATION OF SECTION 7209, SUB -DIVISION Z,OFTHE
NEW YORK STATE EDUCATION LAW.
EDUCATION W."
"ONLY COPIES FROM THE. ORIGINAL OF :THIS SURVEY
Philip
Birmingham
..:MAR N MARKED WITH A LAND: SURVEYORS
SEAL SHALL BE CONSIDERED TO BE VALID TRUE COPIES."
"CERTIFICATIONS INDICATED HEREON SIGNIFY THAT
.THIS SURVEY .WAS PREPARED IN ACCORDANCE NTH THE
:. EXISTING :CODE OFP PRACTICE F LANDSURVEYORS :,
RA CE OR LA. ADOPTED
And
BY THE NEW YORK STATE ASSOCIATION OF PROFESSIONAL
:SHALL
-
LAND SURVEYORS. SAID. CERTTFICATIONS RUN ONLY
'TO THE PERSON FOR WHOM. THE SURVEY IS PREPARED, AND
ON HIS BEHALF TO THE. TITLE COMPANY -:GO GOVERNMENTAL
AL
®
Lorraine
® •
P.Birmingham
(� '{� y
169 Havziand Road
y.�
Queensb ry,
ppq q
New York
ork 12(.iO4
:AGENCY AND :LENDING INSTITUITION LISTED HEREON, AND
1
TO THE ASSIGNEES OF THE LENDING INSTITUTION."
(518) 792-8474
New York
Lie. No. 50135
t New `Yank
Town of Queensbury, Warren County,
Da.tel August 30, 2012
ScoJe ? —30
SHEET 1 OF 1
BIRMINGHAM C1769C
DWG. NO. 06047
289. 14-1-6
.,, .. ONS
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DESCRIPTION