application •
01, Office Use Only
ACCESSORY STRUCTURE
PERMIT APPLICATION
Permit#: -Ptc5,T-
Town ofQueensbnry Permit Fee:$ 125. 60
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net Invoice#: 25 .p
Project Location: 82 Assembly Point Road
Tax Map ID#: 239.12-2-43 Subdivision Name: N/A
CONTACT INFORMATION:
• Applicant:
Name(s): E.Jeffrey Baertschi -
Mailing Address, C/S/Z: 82 Assembly Point Road Lake George, NY 12845
Cell Phone: ( 518 ) 365-2102 - Land Line: ( )
Email: nacar225@gmail.com
• PrimaryOwner(s):
Name(s): E. Jeffrey and Kirstie Baertschi
Mailing Address, C/S/Z: 82 Assembly Poimt Road Lake George, NY 12845
Cell Phone: ( 518 ) 365-2102 Land Line: ( )
Email: ngcar2250gmail.com
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: ( ) R 9Y P u
Email: --�, — -
**List all additional contractors on the back of this form �___
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• , Architect(s)/Engineer(s): TOWN or OUEE.--.Haa'URY
Business Name: BUILDING.8;COCCS
Contact Name(s):
Mailing Address,-C/S/Z:
Cell Phone: ( ) Land Line: ( )
Email:
Contact Person for Building & Code Compliance: Pri<44 -
Cell Phone: ( ) - Land Lihe: ( )
Email:
Accessory Structure Application Revised February 2019
1
I1'
PROJECT INFORMATION:
TYPE: Commercial X Residential
WORK CLASS:
X 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:
2nd floor: •
Total square feet: 276
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$3500
2. If Commercial project,what is the proposed use:
3, Are there any structures not shown on the plot plan? YES. 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: . W.% i.gv
SIGNATURE: ,TLC 71 f DATE: 4//ZV?ei
Accessory Structure Application Revised February 2019