AST-0143-2021 Office Use Only
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ACCESSORY STRUCTURE Permit#: �IC r�ZI
Torun oCQensbury PERMIT APPLICATION permit Fee:$
742 Bay Road,Queensbury,NY 12804 Invoice#: 1125 �
P:518-761-8256 www.gueenstLuU.net Flood Zone? Y N Reviewed By:
Project Location: S ,5- .-J c7 L,
Tax Map ID#: a c� l S..�.._f3 Subdivision Name: (u stAblu/S lo/v
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 56 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: j Q"x f �.r V E
2"d floor: D
a � `AAR 3 20121
Total square feet: �i:
TOWN OF QUEENSBURY
BUILDING&.CODES
Brief description of scope of project:
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Accessory Structure Application Revised January 202!
ADDITIONAL PROJECT INFORMATION:
1. Estirri_at�ed'Cgstt-ofi,C�n�ruCtiari�$ r �
CU O
2. Are there any structurA of shown on the plot plan? ❑YES ONO Explain:
3. Are there any easements on the property? ❑ YES NO
DECLARATION:
1. I 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 If,for any reason,the building permit application is withdrawn, 30%of the fee is retained by the Town of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 certifythat 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:
SIGNATURE: `'- ` DATE:
Accessory Structure Application Revised January 2021
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant: y� �r
Name(s): >����`� _�` "�' �
Mailing Address, C/S/Z: 5 S o z "' l
Cell Phone: 3 Land Line: j I l�.- ����S e/—F
Email:
• Primary Owner(s): 4
Name(s):
D .� «.
Mailing Address, C/S/Z: S
Cell Phone: Land Line:
Email:
❑ Check if all work will be performed by property owner only
• Contractor(s): (List all additional contractors on the back of this form) l
ContractorName(s): , le'v- �iaY�eN Skew key I"4"-�
Contractor Trade: - w ry a t
Mailing Address, C/S/Z:
Cell Phone: Land Line: g- , ? 4 o � fl,g q
E m a i l: W W L4-J s, -s�� ���e,�- 41fi
w,44s
k s,�o7 (document tion must be submitted with this application**
• Arch itect(s)/Engineer(s): /
Business Name: �,� oar as � ul, L� � �� � �rvllS � 1�� ���Ld l 5
ContactName(s): -y �>vv-fir TO �-e /�S�P�r he �£?�
Mailing Address, C/S/Z: l oc7;k .T CT4.9e-�
Cell Phone: Land Line:
Email:
Contact Person for any questions regarding this project:
Cell Phone: C?/- I l �.3 Land Line: S-1
Email: 54 4 1 0) oz, , Gwi
Accessory Structure Application Revised January 2021
NOTES:
7.�
`V MAP REFERENCE:
_
°.f.uer 1.) PARCEL IS SUBJECT TOANY EASEMENTS,COVENANTS.AND �. (�� \ py \ r yyy\FFF��� i. 'LEUCI - JOHN CLENDON ROAD SUBDIVISION'
DESCRIBEDINBOOK 5675 OFOEEDSEATPAGE 3/ONDIIIDNS �O r �� : BY: VAN OUSEN Al$TEVES LAND SURVEYORS AND
V� v,L. 111 j�C NACE ENCINNERING, P.C.
\ nI DATE: MARCH 15, 2076
2.J TiI/S MAP IS LOPYR/GHim 3018VANDUSEN6 STEVES LAND r 1 • ',filly pt 'Z _�'�f{ LAST REVISED: DUNE 12, 2017
SURVEYORS.UNAUTHORIZED ALTERATION OR ADDITION TO TNIS d 1 `�. `- FILED: JUL Y 12, 2017
DOCUMENTIS VIOLATIONOFSECT/ONi169,SUBDIVIS/ONz OF V
1 NEW YORK STATE EDUCATION LAW. / x �9 Ni.t, PLAT 0-13
01
INSTRUMENT N0. 2017-J00006J
p EVE
MAR 2 3 2021 LOT 15
i
�® N OF a EENSI3URY
lU111DIN GOOES- - — — -J
f ,( '18 S 06'30'20° W
P60.00-
W - 1000 GAL.
SEPTIC TANK
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o, � __ OI57 IBUTION I
o Box a
Lot 16
N N
v;nc^�-cr..� Area I a o
Iew-. i 37800.0-Sq. Feet O _
4 - 40 LF ABSORPTION( 0.87x Acres
I _ TRENCHES !
N 360.00'
N 06'30'20° E
RECORD DRAWING NOTE:
A REPRESENTATIVE OF OUR OMGE'NSIFED THE I 1�
SITE DURING CONSTRUCTION AND IT IS MY
OPINION THAT THE SYSTEM IS INSTALLED IN
GENERAL CONFORMANCE WITH THE APPROVED
PLAN AND THIS RECORD DRAWNG. FINAL I I
SURFACE FlNISHING AND TURF ESTABLISHMENT
REMAINS TO BE COMPLETED. I 1
THOMAS CENTER,P.E.
06/I5�12020 I LOT 17
1 SEPTIC SYSTE\II - AS BliILT 13Y NACE ENGINEERING
RECORD DRAWING
INSTALLATION DATE:0412412020 \�
INSTALLED BY-SUPERIOR EXTERIOR EXCAVATING \
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a J•i D�'s er) \Inp nl n tiu'-, nadr Ibr S—le
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St,e'veS 5-1
Foothills Builder s 306115120 SEPTIC RECORD DRAWING
a n C1 S li Y'V e y O v S 2 04/10/20 FINAL UPDATE SHEET I OF 1
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10/21/2020 Amazon.com: 12'x 18'Vinyl Pavilion with Shingled Roof:Garden&Outdoor
t k ` 12' x 18' Vinyl Pavilion with
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TOWN OF QUEENSBURY
"= BUILDING DEPARTMENT
XK:kJti;1;'^; si .:"eT,';."yf �::.`a",,.�e`�a ly....- _`'` /�:.^•e',ly
`>tr Based on our limited examination,comp
liance
":_,:.�����;; � ,� ,'" � .b •�_:.:::��� with our comments shall not be construed as
;V � ,: '�_�J� /�` •�`i"'w indicating the plans and specifications are in
A" full compliance with the Building Codes of
New York State.
�j.
TOWN OF.QUEENSBURY
BUILDING & CODES DEPT.
Reviewed y•
Date:
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