AST-0508-2020 ti
Office Use Only
ACCESSORY STRUCTURE
PERMIT APPLICATION Permit#: � �r'L%��
Town oFQucens6uty Permit Fee:$ Q.-CD Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensburv.net Invoice#:
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Project Location: J '-0/_ Mal/jaw)) -
Tax Map ID #: Subdivision Name:
CONTACT INFORMATION:
• Applicant:
Name(s): -RH(1i
Mailing Address, C S Z: S6 O14e-Wits-} I-f . P. UayIS bo ` i /3-t 0
Cell Phone: (c/if ) -716—D778 Land Line: ( ')
Email: 1r 1,°v.J:a-J*14:1, czvn / 11
• Primary Owner(s): AUG 2 4 Zdt7
Name(s): � T ory� 0
Mailing Address,'C/S/Z:
Cell Phone: ( ) Land Line: ( & Cnn'DURl'
Email:
IN Check if all work will be performed by homeowner only,
• Contractor(s): Workers' Comp docum ation must b bmitted with this application
Contractor Name(s): Ha,f7 O f'e n • ILt );t
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: PIP it RI I I u<5
Cell Phone: ( S 7 S' ) ')9(o- 017 8 Land Line: ( )
Email: m 1 la rvLc,,'r.
Accessory Structure Application Revised February 2019
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: , J ) � 5 .9.*51L5k °Vik 8e/1
/IASQUARE FOOTAGE OF STRUCTURE: /1 `Q 0,5 „f:Lt
'
1st floor: ll, �i{M Otis
NI
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2nd floor: C`- SC1G��Sj
Total square feet: 3 6004 �,0r
itYt
ADDITIONAL PROJECT INFORMATION: Q� ` E�
1. Estimated Cost of Construction:$ )7)0 O,0 0 U"
2. If Commercial project,what is the proposed use:
3. Are there any structures not shown on the plot plan? YES Ca Explain:
4. Are there any easements on the property? 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:
PRINT NAME:"/ ,6r;J!lJ��'
SIGNATURE: DATE: 'SAA1/0
Accessory Structure Application Revised February 2019
APR 0 8 2021
TOWN OF QUEENSBURY
BUILDING& CODES
Zoe
VVEA JIM ELECTRICAL INSPEC77oN SERVICE.INC.
Malu Officc 176 bogy Run Road-Manhelm.PA 17545 ! •'.
:` •. MUNICIPAL CEWMICATE - ELECTRICAL APPROVAL
.,... ;Pertttit No.................... N®.........,......Cert. � 42273 'Cut-in Card No....,...........
:�.v• .Owner �?!°A /,. . t. , .t�'.s,. r....................................................................................
............ ......
Location........... "�..' ..T.,..IZ.r�........
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;Installation Consisting of......,�a-.�.41910A(.%,...ce. .l�.t. .�a^..=........ .4?U.1. ....S.xa.b�'1.1.?.n..�.�..ti..........
....................................................................................................................................................................I..........
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�;;•;'. Installed By....,....:-�`.�� '4. .. .......................................... ...........Lie.No................................................. j w
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The conditionb R)HOwing 6evcrned the issuance of this certificate.and any oerdficam previously issued is
1< •'' This certifl me ottly covers dw electrical equipment and installation conditions us of date. Upon the i :•:`•4s
:introduction of additional equipment or alterations,application shull be promptly made,for inspection. ! ;
' •`'' Inspectors of this Compt,ny shall have the privilege of making; inspection+ at any time, and if its
r' ,rules arc violated.the Company shall have the right to revoke this certificate.
14S*} UatC............ ',a. ..Ir................. tNSpCCTOR sr ! ...............................
~ Member NARA.,I.A.E.i.
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