application Office Use Only
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ACCESSORY STRUCTURE Permit#:
PERMIT APPLICATION Permit Fee:$ ;244 to
mwn of Queensbury
742 Bay Road,Queensbury,NY 12804 Invoice#:
P:518-761-8256 www.queensburv.net
Project Location: 7 q A4k.
L , )4v 10--d-eve
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Tax Map ID#: 2_Q9./7-1-3 Subdivision Na
1E-1IIIVE
CONTACT INFORMATION: IN
AL",b3
• Applicant: •
Name(s): KtA5 . 14 (1 la rd- TOWN or-.ci-d V7-7:MC,Igg IDV
Mailing Address, C/S/Z: - g ) ;,k Dr L.- ivy GO-691av- , an/E.:LOMENT
Cell Phone: ( ) Lansi Line: (,c/ ) 792.. 7 0
Email: ti kk. , 11) o, Cr n 1
••,1
• Primary Owner(s):
Name(s): lz,wcce 11 8_ Mac v- (Th
Mailing Address, C/S/Z: 7A-str L V I 2,
Cell Phone: ( Land Line: ( ) ?7a 57
• (Ac —t qrd 9) a tvo t
. .
• Contractor(s):
Business Name: Hr. 1-71,11,1 T- iie (,( 6—e( c
Contact Name(s): U k aL vvV,
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: ( )
Email:
Of[e/tA (--kkoks.c7vt T-a.11 5
• Architect(s)/Engineer(s):
Business Name:
Contact Name(s): •
Mailing Address, C/S/Z: •
Cell Phone: ( ) Land Line: ( )
Email:
Contact Person for Building& Code Compliance: ?IA gete.,
Cell Phone: ( ) 79? --S7Lod Land Line: ) 6-76,e
Email:
•
Town of Queensbury Building&Code Enforcement Accessory Structure Application Revised April 2017
I .
PROJECT INFORMATION:
TYPE: Commercial Residential
WORK CLASS:
Deck,Open Porch _Solar Panels(w/o rafter upgrades) Carport Cell Tower
Shed _Pavilion, Pole Barn,Canopy _Dock _Gazebo
s/ Detached Garage _Boathouse(with or w/o sundeck) 3-Season Porch
Other(description:
SQUARE FOOTAGE OF STRUCTURE: •
1st floor: 7
2"d floor: . . V�J
Total square feet: J 1 6
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$ [C1 0 0 U -
2. If Commercial project,what is the proposed use: ii
3. Are there any structures not shown on the plot plan? YES NO xplain: jl_- t ' I 1
4. Are there any easements on the property? YES
r e;n tloar5e, i d11 bark i
2.` ' -�0
DECLARATION:
1. I acknowledge that no construction shall be commenced prior to issuance of a'valid permit and will be
completed within a 12 month period.
2. If thework is not completed by the 1 year expiration date the permit may be renewed, subject to fees
and department approval. _
3. I certify that the application, plans and supporting materials are a true and 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.
4. I acknowledge that prior to occupying the facilities proposed I, or my agents, will obtain a certificate of
occupancy.
5. 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: c?\. X,kk
S ki@ 1( I � oCire-JSIGNATURE: A�\&/ DATE:q-- 1, — i-(7°
v p v
Town of Queensbury Building&Code Enforcement Accessory Structure Application Revised April 2017 '