application Office Use Only
ACCESSORY STRUCTURE
PERMIT APPLICATION ^ F
Permit#: AS - 0��-5 '2-0
Town of Quccnsbury
Permit Fee:
742.Bay Road,Queensbury,NY 12804
P:518-761-8256, www.queensbury.net Invoice#: IFj07
Project Location: AV k✓f/bj5kif
Tax Map ID#: Subdivision Name: W ft SY19ce---'
CONTACT INFORMATION:
• Applicant
Name(s): Ic fl7 i
Mailing Address; /S/Z: 5-tri.-z hfrivir
Cell Phone: (5( ) 7'b ' 7(/b Land Line: ( ) =
Email: faurKGUYI St6iGY,Gyi,a-3 J.,k:I - G
• Primary Owner(s):
Name(s): . /44�
Mailing Address, /S ig/G✓(1P4j G G"f- ateetl� /6G'-/
(�"�(
Cell Phone: . • *3b1.y 35 . Land Line
Email: .
0 Check if.all work will be performed by homeowner only
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s):- bY-o
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): 1I
Business Name: _ 2ii$i 5k Ault
Contact-Name(s): a�/fgAt(
Mailing Address,. /S/Z: r � v'5 FA _ i I
Cell Phone:_ (51 ) .7KI�0b7J4cr G/ Land Line: ( )
Email:
Contact Person for Building& Code Compliance: .0 ocic ��,r✓
Cell Phone: ( l ) 7 - **0 Land Line: ( ) .
Email: f Ctms-ErrirctJ-"- a 3 ;vn ,e
Accessory Structure Application Revised February 2019
PROJECT INFORMATION: /Residential
TYPE: Commercial
WORK CLASS:
I/Deck,Open Porch _Solar Panels(w/o rafter upgrades) _Carport _Cell Tower
Shed _Pavilion, Pole Barn,Canopy _Dock _Gazebo
Detached Garage Boathouse(with or w/o sundeck) _3-Season Porch
Other(description:
SQUARE FOOTAGE OF STRUCTURE:
1st floor:
2nd floor:
Total square feet: I t/
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$ ( Iv)'
2. If Commercial project,what is the proposed use:
3. Are there any structures not shown-on the plot plan? YES 6.)Explain:
4. Are there any easements on the property? YES 69)
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. 0
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.
have read and agree to the above:
PRINT NAME: ` ;:/irr 0
SIGNATURE: "✓ DATE: 6
Accessory Structure Application - ' Revised February 2019