Final electrical inspection office Use Only
ACCESSORY STRUCTURE Permit#: -RS— Q-228- 2 2-
Town of Qc Sb PERMIT APPLICATION permit Fee:$ 85'
742 Bay Road,Queensbury,NY 12804 Invoice#:
P:518-761-8256 www.gueensbury.net Flood Zone? Y CN Reviewed By:V"Q
Project Location: 6-7.�iT / �1ftGt� � �itlSgL1e` . 1'
Tax Map ID#: �$� �`C� ' � Subdivision Name. .
PROJECT INFORMATION:
TYPE: Residential ❑ Commercial, Proposed Use:
STRUCTURE:
❑ Boathouse(with or w/o sundeck) ❑ Canopy ❑ Carport ❑ Cell Tower ❑ Deck
❑ Detached Garage.(>300 s.f.) ❑ Dock ❑ Gazebo ❑ Pavilion ❑ Pole Barn ❑ Porch 'A El Ramp
El Shed <300 s.f. El Solar Panels(w/o rafter upgrades) El 3-SeasonPorch 1 Other:oCaKJana
SQUARE FOOTAGE OF STRUCTURE:
1st floor:
0 2nd floor: r
APR 2 7 227 Total square feet: ZZ7
TOWN
OUEENSBURy `1
Brief escrip iotrvf stepjo"ect: G Qbl��.
V- V% O AS bell/La L
Ld-e. e� 4� �'row+ alnd' YZ o
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Accessary Structure Application Revised March 2022
ADDITIONAL PROJECT INFORMATION:
1. Estimated.Cost of Construction:$ L S,mo
2. Are there any structures not shown on the plot plan? ❑ YES K NO Explain:
3. Are there any easements on the property? ❑YES C4 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 If,for any reason,the building permit application is withdrawn,-30%of the fee is retained by the Town of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 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 1, or my agents,,will obtain a certificate of
occupancy.
-.6. I also understand that I/we are required to provide an as-built survey by a fcensed.land surveyor of all newly
constructed facilities prior to issuance of a certificate of occupancy. OA ,
I have read and agree to the above:
PRINT NA E: _
SIGNATU E: DATE: .Z Z 2-
Accessory Structure Application Revised March 2022
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant: 1 `-
Name(s): t)Qv l.«lDe-�lf'21�
Mailing Address, C/S/Z: �WA4 �;16kj 06"1 &
Cell Phone: <:2(bk. *5(P .g4z,9 Land Line:
Email: J., l,a . JtP)04VeU,(° V - t . L'a UA__
• Primary Owner(s):
Name(s):.
Mailing Address; C/S/Z:
Cell Phone: Land Line:
Email:
L7 Check if all work will be performed by property owner only j�o �� wa, _
!k. • Contractods): (List all additional contractors on the back of this form) tX 1
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: tit
Cell Phone: Land Line:
Email
Accessory Structure Application Revised March 2022
COMMONWEALTH ELECTRICAL INSPECTION SERVICE,INC.
Main Office 176 Doe Run Road-Manheim,PA 17545
MUNICIPAL CERTIFICATE - ELECTRICAL APPROVAL
Permit No 42K-PZ% -ZO L Cert. N 8 5 0 0 8 6 Cut-in Card No....................................
Owner...................... .........L:l.. ................................................................................
Location..................', .l........=�fZ,Ccrznt/�....(.a.�...............................................................................
...............
Installation Consisting of......... ........:3.. ................
S �i S
..................................................................................................................................................................................
InstalledBy.............Sz->.rK;..5;e........................................................Lic.No.................................................
The conditions following governed the issuance of this certificate,and any certificate previously issued is
cancelled:-
This certificate only covers the electrical equipment and installation conditions as of datc. Upon thi
introduction of additional equipment or alterations,application shall be promptly made for inspection.
Inspectors of this Company shall have the privilege of making inspections at any time, and if it
rules are violated,the Company shall have the right to revoke this certificate.
Date......... ............... INSPECTOR�...?-rr..% ?�.1 .............................
� Member N.RP.A..I.A.E.I.
9:531 .i11 LTE O,
X Liebetreu; L-0019; 20-270;... C+ ch
TOWN OF QUEENSBURY
BUILDING DEPARTMENT Based on our limited examination,compliance
with our comments shall not be construed as
indicafn�g the plans and specifications are in TOWN OF QUEEiJSBURY
full compliance with the Building Codes of
New York State. BUILDING & CO ES DEPT.
Reviewed By:
--� Date: -
1
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