application Office Use Only
ACCESSORY STRUCTURE
Permit it: 1cc5\ 12.' 2_
4A1
y; PERMIT APPLICATION
Town of Qu bu eensry
Permit Fee: $
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net Invoice#: 12�
Project Location: - -I.0 �V^yl� , Pc
Tax Map ID #: ora i O.-f—r'l Subdivision Name:
CONTACT INFORMATION:
• Applicant:
Name(s): rxt v t d cf Co yk S
Mailing Address, C/S/Z: 5J x-vi Kee 613 4., f IZPv
•
Cell Phone; ( -i ) -- Land Line: (
Email: jay; de
• Primary Owngr(s):
Name(s): 1�G( t�`i ( 6�l I�(C 14P . -la 1-'1h_s
Mailing Address, C/S/Z: S-9 Ltd 1-P_rV& !I ( b tJ-, /I F
Cell Phon : ( h j-5-I- Land Line: (
Email: f at/id C) ( °O'4 ' r 'W
E1 Check if all work will be performed by homeowner only
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: (
Email:
**List all additional contractors on the back of this form
• Arrbit,e.cUsJ/Engi e J
Business .
Contact N (s).
Mailing A ss;t4 1/4:3 2019 II .li
Cell Phoi : ) Land Line: (
Email: TOWN OF OUEENSBURY
BUILDING&CODES
Contact Person for Building & Code Compliance: 3Pt a,
Cell Phone: ( ) Land Line: ( )
Email:
Accessory Structure Application Revised February 2019
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
Detached Garage Boathouse (with or w/o sundeck) _3-Season Porch
Other(description:
SQUARE FOOTAGE OF STRUCTURE:
(-) d, ,,1
1st floor:
2"d floor:
Total square feet:
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$ 200 1
2. If Commercial project,what is the proposed use:
3. Are there any structures not shown on the plot plan? YES Explain:
4. Are there any easements on the property? YES
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 the work 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 ofa certificate of occupancy.
I have read and agree to the above:
PRINT NAME: U VI -�J S
SIGNATURE: 661/ t9aJ ` DATE: /I/1(('
Accessory Structure Application Revised February 2019