application ACCESSORY STRUCTURE Office Use Only
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PERMIT APPLICATION Permit#:
Town of Qccnsbury
Permit Fee:$
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensburv.net Invoice#: 5015
Project Location: 20 Amethyst Dr, Queensbury NY
Tax Map ID #: 93-161 (Building Permit#) Subdivision Name: Ambershire
CONTACT INFORMATION: _—
LE cgovEiTil
• Applicant:
Name(s): Gabriel& Heather Widler OCT o
Mailing Address, C/S/Z: 20 Amethyst Dr, Queensbury NY 12804 _
505 977-4823 TPWN OF �UFF:hf:�;ragr—
Cell Phone: ( ) Land Line:
Email: indig00family(a�gmail.com " ' '`' �
• Primary Owner(s):
Name(s): ,,war ors krip&'c ant-
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): Versatile Shed& Gazebos
Contractor Trade: 669 Saratoga Rd, Wilton NY 12831
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: ( 518 ) 584-7924
Email: sheds(a versatilesheds.com
**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: pr-pQ‘tc�,,�t'
Cell Phone: ( ) Land Line: ( )
Email:
Accessory Structure Application Revised February 2019
PROJECT INFORMATION:
TYPE: Commercial X Residential
WORK CLASS:
Deck,Open Porch _Solar Panels(w/o rafter upgrades) _Carport _Cell Tower
X 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: 140
2nd floor:
Total square feet: 140
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$ 4,000
2. If Commercial project,what is the proposed use:
3. Are there any structures not shown on the plot plan? YES NO Explain: NQ just the home and shed
4. Are there any easements on the property? YES NO 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: Heather Widler
SIGNATURE:`.-���67 , "/eg DATE: 10/15/2020
I
Accessory Structure Application Revised February 2019