AST-0193-2021 Office Use Only
ACCESSORY STRUCTURE Permit#: -N!S! ^ d 19 — 20 Z)
Town ofQucensbury PERMIT APPLICATION Permit Fee:$
742 Bay Road,Queensbury,NY 12804 Invoice#: 15-Y
P:518-761-8256 evww.gueensbury.net Flood Zone? Y N Reviewed By:
Project Location: ��1r�
Tax Map ID#: 3109 Subdivision Name:
PROJECT INFORMATION:
TYPE: BI 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: C(
2"d floor: (II�
Total square feet: 1 C�
Brief description of scope of project:
MI
OVI 5 2o21UEENSSURY
& CODES
Accessory Structure Application Revised January 2021
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$ U
2. Are there any structures not shown on the plot plan? OYES ,9.(VO Explain:
3. Are there any easements on the property? ❑ YES NO
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 If,for any reason,the building permit application is withdrawn,30%of the fee is retained by the Town of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. If the work 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 a true 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 1/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: &7�6,
SIGNATUREc"_.t � .,_ DATE: I
Accessory Structure Application Revised January 2021
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant: A
Name(s):
Mailing Address,C/S/Z: v�� (_1' ��5 ( ou'u oS
Cell Phone: jt"I Land Line:
Email: ���Hc �(`' cL� Czh C�c3 f CG 'f1
• Primary Owner(s):
Name(s): ,c} &Jec"
Mailing Address,C/S/Z:
Cell Phone: Land Line:
Email:
'[ heck if all work will be performed by property owner only
• Contractor(s): (List all additional contractors on the back of this form)
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)/Engineeds):
Business Name:
Contact Name(s):
Mailing Address,C/S/Z:
Cell Phone: Land Line:
Email:
Contact Person for any questions regarding this project: fir`
Cell Phone: Land Line:
Email:
Accessory Structure Application Revised January 2021
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BUILDING DEPARTMENT 10 , x'.� 6 ' Q
Based on our limited examination,compliance TOWN OF QUEENSBURY
with out comments shall not be construed as
Indicating the.plans and specifications are in 3 �1 BUILDING & CODES DEPT. o
II compliance� w the Building Codes of 12 0 f t W
NewReviewed By- �' �
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