application 7,1
Office Use Only
1
I Permit#:ACCESSORY STRUCTURE � � _ o (� 2 0 i .
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PERMIT APPLI �,
Town of Queens6 D t ee $ ,S r U
742 Bay Road,Queensbury,NY 12804 t� +
P:518-761-8256 www.queensbury.net OCT 15 e#: /l Li
2019
Project Location: 131 West Mountain Ro.d_IOWN OF CUEBNSBURY
BUILDING& CODES
Tax Map ID#:_308.17-1-3 Subdivision Name:____-
CONTACT INFORMATION:
• Applicant:
Name(s): Daniel Green
Mailing Address, C/S/Z:_131 West Mountain Road_Queensbury
N.Y. 12804
Cell Phone:_( ) Land Line: _(518)_792-6801
Email:_dcgreenl@verizon.net
• Primary Owner(s):
Name(s): Daniel & Carolyn Green Green family Irrev Inc Only Tr
Mailing Address, C/S/Z:_131 West Mountain Road Queensbury, N.Y.
12804
Cell Phone:_( ) Land Line: _(518)792-6801
Email:
►-� Check if all work will be performed by homeowner only Site Preparation
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line: _( )
Email:
**List all additional contractors on the back of this form
• 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:
Accessory Structure Application Revised February 2019
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PROJECT INFORMATION:
TYPE: ❑ Commercial 0 Residential
WORK CLASS:
❑ Deck,Open Porch ❑ Solar Panels(w/o rafter upgrades) ❑ Carport ❑ Cell Tower
►=� Shed ❑ Pavilion,Pole Barn,Canopy ❑ Dock ❑ Gazebo
❑ Detached Garage ❑ Boathouse(with or w/o sundeck) ❑ 3-Season Porch
❑ Other(description:
SQUARE FOOTAGE OF STRUCTURE:
1st floor:
2"d floor:
Total square feet: 240
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$ 5500
2. If Commercial project,what is the proposed use:
3. Are there any structures not shown on the plot plan? YES NO Explain:
4. Are there any easements on the property? 0 YES NO
DECLARATION•
1. 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. I 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. I acknowledge that prior to occupying the facilities proposed I, or my agents, will obtain a certificate of
occupancy.
5. 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:
Accessory Structure Application Revised February 2019
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PRINT NAME: Daniel Green
SIGNATURE: 91 , Q /91t,ky1 DATE: f 0 —
REQUIREMENTS FOR SUBMITTAL:
1. Completed Accessory Structure permit application
TWO(2) COPIES OF THE FOLLOWING:
2. Structural drawings, which include:
a. Signed &sealed architect or engineer stamp IF the cost of construction is over$20,000
b. Floor plan
c. Foundation plan
d. Cross sections
e. Elevations
f. Window& Door schedules—printed on the drawings is acceptable
g. Calculation sheet for natural light,ventilation &emergency egress
3. Plot plan, using a survey map if possible,which includes:
a. Drawn to scale (i.e. 1 inch =30 feet)
b. Indicate proposed changes, with setbacks
c. Include all structures on the property
d. Include location of water supply(well or water lines)
e. Include location &configuration of septic system or sewer line
4. REScheck(residential projects) or COMcheck(commercial projects), signed and stamped—
www.energycodes.gov
5. Workers' Comp insurance information for all contractors involved.
ADDITIONAL INFORMATION:
1. Any changes to the approved plans prior to or 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, 20% of the fee is retained by the
Town of Queensbury. After 1 year from the initial application date, 100% of the fee is retained.
Accessory Structure Application Revised February 2019