Test Application _W
Office Use Only
ACCESSORY STRUCTURE Permit.#: PVS5V
Town ofCLcensbury PERMIT APPLICATION Permit Fee:5 14to
742 Bay Road,Queensbury,NY 12804 Invoice#: /mil
P:518-761-8256 www.gueensbury.net' Flood Zone? Y ( N ) Reviewed By:�
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Project Location:
Tax Map ID#: I Subdivision Name:
DROJECT iNMPKAIAT-iniy•
TYPE: K Residential ❑ Commercial, Proposed Use:
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❑ Boathouse(with or w/o sundeck) ❑ Canopy ❑ Carport ❑ Cell Tower ADeck
I Ii natarhad rar?oa(�3nn c•f•1 ❑ [lnrk ❑ C;a�ahn FI Pavilion ❑ Polp Rarn ❑ Pnrrh 1-1 Ramn
❑ Shed(<300 s.f.) ❑ Solar Panels(w/o rafter upgrades) ❑ 3-Season Porch ❑ E r E � E
SQUARE FOC!T AGE OF S T RUC l URE:
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JUN 0 9 2021
1st floor: 5 f 2 csi �
2URY
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Total square feet: I
Brief descrint_inn"nf iscope of project p r/� �n J� In,1
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Accessory Structure Application Revised January 2021
AnnlTlnRIAl DDnlC!'T 1AICnDRfiATInIU-
1. Estimated Cost of Construction:$ I O
2. Are there any structures not shoe.u.n on the plot plan? DYES A Explain:
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3. Are there any easements on the property? ❑ YES NNO
DEGl_A1RA-`I"ION:
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 If,for any reason,the building permit application is withdrawn,30%of the fee is retained by the Town of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 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 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.
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Accessory Structure Application Revised January 2021
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• Applicaant• p� p
Name(s):� U J `� U Q h
Mailing Aidress, C/S/Z: n�1 I �0 U'
Cell Phone: �� �L �I ` PJ L'and L��
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• Primary Owner(s):
Name(s): MW MOM( 411 �l
Mailing Address, C/S/Z: 19tr (� lnq QU
Cell Phone: 51$ q�i I Land Line:
Email: �' � US ( ��, � b�lll �� � ® US• � � •
Pl1eck- :j all wort- will be performed by property
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�.Ilc�.n 11 all work- will' uc performed Illcu by pl V�JCI �y VWItCI V��
• Contractor(s): (List all additional contractors on the back of this form)
Contractor Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: Lard Line:
Email:
"Workers' Cornp.documentation roust be submitted with this application *
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Business Name:
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
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Cell Phone: ^�I(� I�(,�(�(� Land Line: /�I,�Email: A lur@U O I�� �I .
Accessory Structure Application Revised January 2021