AST-0443-2020 yl
Office Use Only
ACCESSORY STRUCTURE
PERMIT APPLICATION Permit#: AS` -
Town ofQeensbury 12-5
742 Bay Road,Queensbury,NY 12804 Permit Fee:$
P:518-761-8256 www.queensbury.net Invoice#: VA-co
Project Location: 15 7 I R t ctC emaCa,eern,c-kr)n Orr) 1&r5V-(
Tax Map ID#: ,Q6C2 3- l- ( 7 Subdivision Name:13/A-
CONTACT INFORMATION:
• Applicant:
Name(s): egelnecca.. Lee
Mailing Address, C/S/Z: 15'71 Aida gocc_cr at)tee►sbrirr _i (awv zf
Cell Phone: (51� )39 I V 3e?I,P `' Land Line: �515r ) Qa3 -Cars
Email:ticcIcecix..404.4 berkes tfyou I . ccnn
• Primary Owner(s):
Name(s): M
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
Contractor Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: (
EIT
Email: V
**List all additional contractors on the back of this forF AUG 0 4 2020
• Architect(s)/Engineer(s): TOWN OF QUEENSBURY
Business Name: BUILDING& cc irsW-
Con fact Name(s):
Mail ng Address, C/S/Z:
Cell 'hone: ( ) Land Line: ( )
Ema I:
Contact Person for Building&Code Compliance: A??\
Ct
Cell Phone: ( ) Land Line: ( )
Email:
Accesso :Structure Application Revised February2019
PROJECT INFORMATION:
TYPE: Commercial ,4„/ 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: L)6 k
Total square feet: 4 10'I
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$ 3500
2. If Commercial project,what is the proposed use: u1A
3. Are there any structures not shown on the plot plan? YES NO Explain:
4. Are there any easements on the property? YES 1V0
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 thework 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:a. LYE (-ed-
SIGNATURE. ��� DATE:
Accessory Structure Application Revised February 2019