application ! ,, Office Use Only
r ACCESSORY STRUCTURE
J Permit#: P \ ( - - 201
PERMIT APPLICATION
Town of Quccnsbury
Permit Fee:$
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net Invoice#: rl-$q
Project Location: 8 c ,eek—,e
Tax Map ID#: 30\�� ~Z -31 Subdivision Na E V 15
CONTACT INFORMATION: JUL 15 2019 J
• A�p licant: TOWN OF QUEENSBURY
Name(s): Jont; k-a -- BUILDING& CODES
Mailing Address, C/S/Z: �� u€ -
Cell Phone: ( 5k` ) 53'8 '-V 9 Land Line: {
Email:
• Primary Owner(s):
Name(s): P eic_e V1t
Mailing Address, C/S/Z:
Cell Phone: { ) Land Line: (
Email:
❑ Check if all work will be performed by homeowner only
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s):
Contractor Trade:
Mailing Address, C/S/Z: `cl
Cell Phone: ( Sid ) 4o'ij3 2_532 Land Line: {
Email: &e.3 b.c,9 yy\c(\
**List all additional contractors on the back of this form
• Architect(s)/Engineer(s):
Business Name:
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: { ) Land Line: (
Email:
Contact Person for Building & Code Compliance: .)4.-4,4, (V-) ,X\�
Cell Phone: ( 506 ) Cv(e,.? -ZS3Z_ Land Line: (
Email: �uX,\ey C\Le>?,-'n C. yCaN
Accessory Structure Application Revised February 2019
PROJECT INFORMATION:
TYPE: Commercial x Residential
WORK CLASS:
Deck,Open Porch _Solar Panels(w/o rafter upgrades) Carport Cell Tower
Shed Pavilion, Pole Barn, Canopy Dock - Gazebo
Detached Garage Boathouse (with or w/o sundeck) 3-Season Porch
Other(description:
SQUARE FOOTAGE OF STRUCTURE:
1st floor:
2"d floor: (�
Total square feet:
ADDITIONAL PROJECT INFORMATION:
Li e-
1. Estimated Cost of Construction:$ I
2. If Commercial project,what is the proposed use:
3. Are there any structures not shown on the plot plan? YES NOS 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. Ifthework 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: --)0 n
SIGNATURE: DATE: ? /
Accessory Structure Application Revised February 2019