application 4-
4
111 Office Use Only
ACCESSORY STRUCTURE
PERMIT APT IJ E 0 w i1 ` 1S-r—o�{2-s�1Dhq
Town of(ZucYnsbury ? iI Fee:$ 5' V v
742 Bay Road,Queensbury,NY 12804 JUN
P:518-761-8256 www.queensbury.net U 21 2O19 i ce#: ! V�
Project Location: 3`(May(er C ortirt,n TifAiveF,COLFXpi Y
Tax Map ID#: )_40•I3-I-3 Subdivision Name: Hi(Q„d park POO
CONTACT INFORMATION:
• Applicant:
Name(s): Pa; Yortrf
Mailing Address, C/S/Z:✓ Queehital 3q Maj -- Co.imws North ►I) `F
Cell Phone: ( (18 ) 9 rr -s,j Land Line: (
Email: b y cteph,,6 /63,(OM
• Primary Owner(s):
Name(s): 1-(oi Val
Mailing Address, C/S/Z: (�uR,„1h�r�/ ?q Marry (or,.+,c., /lcktII
Cell Phone: (5-I% ) qrT erg) Land Line: (
Email: ti yuefte 4 a 6; co*
❑ Check if all work will be performed by homeowner only
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): tic*rcier - OrtG
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: (
Email:
**List all additional contractors on the back of this form
• Architect(s)/Engineer(s):
Business Name:
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: (
Email:
PContact Person for Building & Code Compliance:
Cell Phone: ( 5t ) 45Z1)? Land Lin ( )
Email:
Accessory Structure Application Revised February 2019
PROJECT INFORMATION:
TYPE: Commercial x 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:
1st floor: I) Y. (6, f 0 ,s 1�,
2"d floor:
Total square feet:-- r- (6 0
ADDITIONAL,PROJECT INFORMATION:
1. Estimated Cost of Construction:$ boo . 00
2. If Commercial project,what is the proposed use:
3. Are there any structures not shown on the plot plan? YES NO Explain:
4. Are there any easements on the property? YES NO
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: 4-1CUL 0.219
SIGNATURE: DATE: ‘,/.2.� . .,5
11
Accessory Structure Application Revised February 2019