application Foot, (d iv
�` Office Use Only
Z ACCESSORY STRUCTURE
PERMIT APPLICATION Permit#: Ai- 3560 )1�j
Town of Queensbiuy
Permit Fee: $ (/ 7 yr .GtieI
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net Invoice#: 1(p0 ?"-
Project Location: -1 Y J I�`r_Ll ect.)� Pb - <.t C+L - S o�.4_ I S(
t
111
Tax Map ID #: Subdivision Name:
gea �_
CONTACT INFORMATION: D `i� p � �
• A licant: f;a v li
r!
Name(s): ' �liC.h l 1 llllT / J�`C.$�) �C�t� key �
Mailing Address, C/S/Z: l iY-ecJ Ou Aor-ocd�. .0 �-� ' 1°0l�� R;
NT
Cell Phone: ( �c ) () - 01+1 Land Line: ( )
Email: Ia)P,IAT,1� EirffctL-: C_ev .
• Primary Owner(s):
Name(s): IQ a CO L 11.AC-i,t''CA4 V 1
Mailing Address, C/S/Z: 3-1 Nye,ci cx,2_;10r0CK kci • Qui-e til
Cell Phone: (5-t g ) t-l-C -H-I f T7 Land Line: ( )
Email: Y(Co J e rv)C:i Ca..- `1 C or--)&L L , c O Irv-)
C . 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: ( ) r Laid ine: ( )
Email: i . i
/
**List all additional contractors on t, e�''a0c his form ,
II z
• Architect(s)/Engineer(s):
t
Business Name:
Contact Name(s): V
Mailing Address, C/S/Z: Landp,i1nAl.� 1 ('�Cell Phone: ( ) ": ��'�)
Email: t ,-/P
'
I
Contact Person for Building & Code Co i nce:
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
CA
X Other(description: ""; ?AU
SQUARE FOOTAGE OF STRUCTURE:
1st floor: �', ��1� "
2nd floor:
Total square feet: 1-1-
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ ICJ C'( ;"
2. If Commercial project, what is the proposed use:
3. Are there any structures not shown on the plot plan? YES NCO Explain:
4. Are there any easements on the property? YES 1)
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 of a certificate of occupancy.
I have read and agree to the above: '''�
PRINT NAME: .cirt if r' -c. l�l ro.._±
SIGNATURE: " 1 DATE: $
Accessory Structure Application Revised February 2019