application � �^° "-'r 4 6 Office Use Only
ACCES TRUCTOI�E — 7
PER I
I Permit#: A 5.% (� ( 2�
Town ofQaccnsbury i Permit Fee:$ 7��
742 Bay Road,Queensbury,NY 128 4 --- %��;EE J �; i
AWN OF =ul~�6 Invoice#:
P:518-761-8256 www.queensbu .net T BUI DING Ex(�q; %''`
Project Location: 18 Western Reserve Trail
Tax Map ID#: 36 � e
- l' l 3 Subdivision Name: Western Reserve Trail
CONTACT INFORMATION:
• Applicant:
Name(s): Kenneth Reynolds__,
Mailing Address, C/S/Z: 18 Western Reserve Trail
Cell Phone: (518) 744-6326 Land Line: _(
Email: kenreynolds1226@gmail.com
• Primary Owner(s):
Name(s): Same as above
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line: _(
Email:
Check if all work will be performed by homeowner only
• 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:
Cell Phone:_( ) Land Line: _(
Email:
Accessory Structure Application Revised February 2019
PROJECT INFORMATION:
TYPE: ❑ Commercial ❑X Residential
WORK CLASS:
❑ Deck, Open Porch El Solar Panels (w/o rafter upgrades) ❑ Carport El Cell Tower
❑ Shed El Pavilion, Pole Barn, Canopy El Dock ❑ Gazebo
❑ Detached Garage ❑ Boathouse(with or w/o sundeck) ❑ 3-Season Porch
El Other(description:
SQUARE FOOTAGE OF STRUCTURE:
1st floor: 288 sq/ft
2nd floor:
Total square feet:288 sq/ft
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$2,000
2. If Commercial project,what is the proposed use:
3. Are there any structures not shown on the plot plan? YES X NO Explain:
4. Are there any easements on the property? ❑ YES IZ 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:
PRINT NAME: Kenneth Reynolds I
SIGNATURE: DATE: L/ �Lj
Accessory Structure p 'cation Revised February 2019