application Office Use Only
(.,;::*'-) ) ACCESSORY STRUCTURE Permit#: \ , 2,-CA6 Iowa al*Queensbury
PERMIT APPLICATION
742 Bay Road,Queensbury,NY 12804 Permit Fee: $ Z
5._____n c_______
P:518-761-8256 www,pueensbury net Invoice#:
Project Location:
Tax Map fD #: 2.2.9 .11-1 " I.
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ACT Subd v ti 1E40/
CONTACT •
INFORMATION:
• A t.
lica [ocijjjI0 2018 LI
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Name(s): 0L. CI TOVVI� ®F QUNSBURY
Mailing Address, C/S/Z::}� O t3U!!nit��&�E utES
Cell Phone; jj ) � / . r �e, Z
Email: 3Q ) Land Line:
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• Primary Owner(s):
Name(s): tj.khe, ef, �CX.f S
Mailing Address, C/S/Z: 'Pa.dd i n
Cell Phone: ill �0� f ron U 1 1 Io 0
7 -i? y
Email: Land Line: )
• Contractor(s)•
Business Name: 0
Contact Name(s): +I
Mailing Address, C/S/Z: .O ,
Cell Phone: S) '7d
) 9 l • `l01 i 5
Email: Land Line: )
n3f-r u +1 o . CO
• Architect(s)/.En ineer(s):
Business Name:
1 t it7o oc-laZtz
Contact Name(s): '
Mailing Address, C/S/Z.
Cell Phone: ) ha >� C
Email: Land Line: S J I28L15
Contact Person for Building & Code Compliance:
Cell Phone: 518 )`�9 j --7 0 I I Ozu cc, a_
Email: Land Line: )
10 ciald C.O Lk ion.
Town of Queensbury Building&Code Enforcement
Accessory Structure Application Revised April 2017
PROJECT INFORMATION:
V
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:
1st floor:
2'floor:
Total square feet: q 00
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ 6S,GQO.
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 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:T C&.fl findeLnd
SIGNATURE: '•— _ � ��f DATE: /0 haff
Town of Queensbury Building&Code Enforcement Accessory Structure Application Revised April 2017