application Office Use Only
ACCESSORY STRUCTURE Permit#: PCSTI °A%. "2a 20
- PERMIT APPLICATION Permit Fee: $ 12_5
Town of Queensbury
742 Bay Road,Queensbury,NY 12804 Invoice#: 2-1
P:518-761-8256 www.queensbury.net
Project Location: _19 WINTERGREEN RD_
Tax Map ID#: 302.17-1-31 Subdivision Name:
I AUG 14 2022 -7
CONTACT INFORMATION: TOWN F— 6:�..-�•
• Applicant: . L?':�-('OL C`-� tiy,O V�'` t
Name(s): _TIMOTHY JOHNSTON
Mailing Address, C/S/Z: _19 WINTERGREEN RD, QUEENSBURY NY 12804
Cell Phone: _(518)361-8048 Land Line: _( )
Email: TIMMER094@GMAIL.COM
• Primary Owner(s):.
Name(s): TIMOTHY JOHNSTON
Mailing Address, C/S/Z: 19 WINTERGREEN RD,QUEENSBURY NY 12804.
Cell Phone: _(518)_361-8048 Land Line: _( )
Email: TIMMER094@GMAIL.COM
ECheck 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: _( ) r
Email:
Accessory Structure Application Revised February 2019
Contact Name(s): Opp\tc,c„nt—.
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line: _(
Email:
PROJECT INFORMATION:
TYPE: ❑ Commercial /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: 2tO
2"floor:
Total square feet: .
ADDITIONAL PROJECT INFORMATION:
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1. Estimated Cost of Construction:$
2. If Commercial project,what is the proposed use:
3. Are there any structures not shown on the plot plan? NO Explain:
4. Are there any easements on the property? ❑ YES I11,-IGO
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
Accessory Structure Application Revised February 2019
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: / ; 0 / i--•7 `
SIGNATURE: � ZO
� � DATE: I
r.
FY
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 Tight, 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.
Accessory Structure Application Revised February 2019