AST-0725-2021 W-m
Office Use Only
ACCESSORY STRUCTURE _ Permit#: �\�-.O 72-5. 1sa-ZI.. .
row orQ�bury PERMIT APPLICATION Permit Fee:$. r
74.2 Bay_Road,Queensbury,NY 1280.4 Inv_oile#:
P:518-761-8256. . .www.g ue6nsbury.net
Flood Zone?- Y N Reviewed By:'
Project Location: ,JCUG��i'
Tax Map ID#: �, Subdivision Nam
PROJECT.INFORMATION:
:. : OCT 0 1 2021
TYPE: : Residential ❑ ,Commercial; Proposed Use: �l
TOWN OF QUEENS<3URY
t3UILDING&CODCS
STRUCTURE:
N.Boathou a(with or w/o sand'eck) ❑ Canopy ❑ 'Carport ❑ CeII TowerDeck fJ�°�
5�I he i✓ .
❑ Detached Garage($300:s.f.) . ❑Dock I]Gazebo ❑ Pavilion ❑:Pole Barn: . ❑ Porch ❑.Ramp
El Shed(<Wo.s.f.)' ❑ Solar_Panels(w/o rafter upgrades) ❑ 3-Season,Porch. ❑ Other:
SQUARE FOOTAGE OF STRUCTUREt
1st floor:.
2nd floor:
Total square feet:
. 1 I
All
Brief description of scope of project
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Accessory Structure Application Revised January 2021
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ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$ /e'le v0 v
2. Are there any structures not shown on the plot plan? ❑YES -WNO Explain:
3. Are there any easements on the property? ❑ YES LYNO
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 If,for any reason,the building permit application is withdrawn, 30%of the fee is retained by the Town of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 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 certificate of occupancy.
I have read and agree to the above:
PRINT NAME: Qom, n
SIGNATURE: DATE: y
Accessory Structure Application Revised January 2021
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): 4► 1 p ions-tcu- c`f t o ✓1� �c�5arr1 �aj(S �� 1��3 I
Mailing Address, C/S/Z: 51 C 200DI 'I 1' >
Cell Phone: Land Line: ,51 Sl 799'-033 F-
Email: C(i-)dya C� h; ((+ofcOv)5fCUL eo .
• Pri arX Owners :
Name(s): ri GIB Con not —5
Mailing Address, C/S/Z: Q 5 P-be-"��5� U2en Sb`L,ry, 0�
Cell Phone: Land Line: ,S/,�'' 4�2
Email: e i^d LL 6be ice' 6—D8
❑ Check 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**
• Arch itect(s)/Engineer(s):
Business Name: kyan P, G .
Contact Name(s):
Mailing Address, C/S/Z: V0 QQ<,5C[� l�-�C' t�5 FGL«51 I `�� ���0�
Cell Phone: Land Line:
Email:
W WN . of ujrpe , Co Wl
Contact Person for any questions regarding this project:
Cell Phone: Land Line: 5 (g r7c( 9.-d -a S
Email:
Accessory Structure Application Revised January 2021