2024-0090 j
Office Use Only
ACCESSORY STRUCTURE Permit#: ZDL- OOQ•
PERMIT APPLICATION 1 1 fl
Town ofQureenibury> Permit Fee:$
742 Bay Road,Queensbury,NY 12804 - Invoice#: ZO 2.1- _O 1�
P:518-761-8256 www.aueensburv.net
Flood Zone? N Reviewed B�
Project Location:
Tax Map ID#: l a i I Subdivision Name:
PROJECT INFORMATION: ..�- ---��
TYPE: ;! Residential 0 Commercial, Proposed Use: \ FEB 20 2C24 \
STRUCTURE;
•
❑ Boathouse(with or w/o sundeck) ❑ Canopy ❑ Carport 0 Cell Tower 0 Deck
❑ Detached Garage(>300 s.f.)XDock 0 Gazebo _ ❑ Pavilion ❑ Pole Barn ❑ Porch 0 Ramp
❑ Shed(<300 s.f.) 0 Solar Panels(w/o rafter upgrades) ❑3-Season Porch 0 Other:
SQUARE FOOTAGE OF STRUCTURE:
1st floor:
2nd floor:
Total square feet: 1.-
Brief description of scope of project:
Iwo Afti
•
• Accessory Structure Appllcativn Revised January 2021
•
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$15,000.00
2. Are there any structures not shown on the plot plan? DYES )NO Explain:
3. Are there any easements on the property? ❑YES X 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 If,for any reason,the building permit application is withdrawn,30%of the fee is retained by the Town of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. If the work is not completed by the 1 year expiration date the permit may be renewed, subject to fees
and department approval.
4. I 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. I acknowledge that prior to occupying the facilities proposed I, 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 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: 14,6
SIGNATURE: DATE: l S �sl
Accessory Structure Application Revised January 2021
a
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): Best Built Docks
Mailing Address, C/S/Z: 1276 Ridge Rd Queensbury, NY 12804
Cell Phone: 518-361-5735 Land Line:
Email: bestbuiltdocks@gmail.com
• Primary Owner(s):
Name(s): Brian & Lynne Backus (Rutnick)
Mailing Address, C/S/Z: 2233 Brickyard Rd Canandaigua, NY 14424
Cell Phone: 518-461-8240 Land Line:
Email: bbackus211 e.gmail.com
0 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): Best Built Docks
Contractor Trade: Dock Builders -
Mailing Address, C/S/Z: 1276 Ridge Rd Queensbury, NY 12804
Cell Phone: 518-361-5735 Land Line:
Email: bestbuiltdocks( gmail.com
**Workers' Comp documentation must be submitted with this application**
iQ -V a- Gyetoilo
• 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: Karl Brenneisen
Cell Phone: 518-361-5735 Land Line:
Email: bestbuiltdocks@gmail.com
Accessory Structure Application Revised January 2021
ADIR0NDACK NIDE LAKE GEORGE,NY Brian Backus
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