AST-0189-2021 ., Office Use Only s�
ACCESSORY STRUCTURE Permit#:
Town ofQaeensbury PERMIT APPLICATION Permit Fee:$
742 Bay Road,Queensbury,NY 12804 Invoice#: .551ci.5
P:518-761-8256 www.gueensbury.net
Flood Zone? Y N Reviewed By:
Project Location: /Q IN, kaoE/s ��vE
<! EVg A SOUR-f',/JV
Tax Map ID#: 3c>$. Co — l — 37 Subdivision Name:
PROJECT INFORMATION: -
TYPE: X Residential ❑ Commercial, Proposed Use:
STRUCTURE:
❑ Boathouse(with or w/o sundeck) ❑ Canopy ❑ Carport ❑ Cell Tower ❑ Deck
❑ Detached Garage (>300 s.f.) ❑ Dock ❑ Gazebo ❑ Pavilion ❑ Pole Barn ❑ Porch ❑ Ramp
%Shed (<300 s.f.) ❑ Solar Panels(w/o rafter upgrades) ❑ 3-Season Porch ❑ Other:
SQUARE FOOTAGE OF STRUCTURE:
1st floor:
Znd floor: E 99 n V E
A�nn
Total square feet: '� D
"r's� APR 0 2 2021
Brief description of scope of project: TOWN OF QUEENSBURY
BUILDING &CODES
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Accessory Structure Application Revised January 2021
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): C-,iw) LJ�2Nc�
Mailing Address, C/S/Z:
Cell Phone: st &- &3'7 //S-'7 Land Line:
Emai1: 22 <-10 (ImA,f - cowl
• Primary Owner(s):
Name(s):6:,,,4b GcJ,,,zA/a2
Mailing Address, C/S/Z:
Cell Phone: -+5 Land Line: --
Email:- sE as �riove
❑ Check if all work will be performed by property owner only �icc
• Contractor(s): (List all additional contractors on the back of this form) A
Contractor Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
"Workers' Comp documentation must be submitted with this application"
• Architect(s)/Engineer(s):
Business Name:
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
Contact Person for any questions regarding this project:
Cell Phone: Land Line:
Email:
Accessory Structure Application Revised January 2021
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$ C_&,00O (("Z-c
2. Are there any structures not shown on the plot plan? ❑YES 1KNO Explain:
3. Are there any easements on the property? ❑ YES XNO
DECLARATION:
1. 1 acknowledge that no construction shall be commenced prior to the issuance of a valid permit and will be
completed within a 12 month.period.Any changes to the approved plans prior to/during construction will require
the submittal of amended plans,additional reviews and re-approval.
2. If,for any reason,the building permit application is withdrawn, 30%of the fee is retained by the Town of
Queensbury.After 1 year from the initial application date, 100%of the fee is retained.
3. Ifthework is not completed by the 1 year expiration date the permit may be renewed, subject to fees
and department approval.
4. 1 certify that the application, plans and supporting materials are atrue and a 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.
5. 1 acknowledge that prior to occupying the facilities proposed I, or my agents, will obtain a certificate of
occupancy.
6. 1 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: IKJ.
SIGNATURE: . 1 DATE: j f 3 oI7 J
Accessory Structure Application Revised January 2021
ILI.
7,
E C E E
APR rib Y21
TOWN OF COE'E S
BULDING & CO E R)P.,IG CODES.—
Reviewe
Date:
308-6-1-37 AST 0189-2021
Warner, Chad
10 Michaels IN
TOWN OF QUEENSBURY Shed
BUILDING DEPARTMENT 240 s.f.
Based on our limited examination,compliance
with our comments shall not be construed as
indicating the plans and specifications are in
full compliance with the Kilding Codes of
New York State.
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APR 07
TOWN OF QUEFN9B =„�
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