application Office Use Only
ACCESSORY STRUCTURE
% Permit#: I Ozlot)
. PERMIT APPLICATION
Town of Quccnsbury 1
Permit Fee: $
742 Bay Road,Queensbury,NY 12804 62�
P:518-761-8256 www.queensbury.net Invoice#: - p
Project Location: 46 Lc.)ir ir5\
Tax Map ID #: q6, r t - ( -Z Subdivision Name: k-01,vur;.a e S
CONTACT INFORMATION:
• Applicant:
Name(s): v
Mailing Address, C/S/Z: (04 gt to-to C_ i2- 1 4 (
Cell Phone: ( c1S ) 7' 1 - 1 SA-4 Land Line: ( 5( ) 147, - (3?4 *
Email: ( k r etAh ,^ G 4- C- 5 W.e.:1( • C-Dvv\
• Primary Owner(s):
Name(s): JOlet.- *Nca-
Mailing Address, C/S/Z: 4$ lMk, Uarhe t 051'1:vs At•ioEe- o 2d0 S
Cell Phone: ( ":,( 1 ) 4-13 11 \ 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): �= ►\ �,t�}� u��
Contractor Trade: c�..(,rf(•i
Mailing Address, C/S/Z: 64- (z,,„,1 11-41 uy
Cell Phone: ( 51 ) 7`t( Land Line: ( i;l.. I )
Email: c0vtA4r
**List all additional contractors on the back of this form D ,E C
• Architect(s)/Engineer(s): JUL 0 $ 2019
Business Name: (\
Contact Name(s): TOWN OF QUE NSEU.RY
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: (
Email:Contact Person for Building & Code Compliance: t`ll ^, ki.ic„,k,
Cell Phone: ( ) 1 CCU - 104-G, Land Line: ( .St) )
Email: 14,2. .1 t em u..
Accessory Structure Application Revised February 2019
PROJECT INFORMATION:
TYPE: Commercial V 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 i
2"d floor:
Total square feet: I '12- 9f
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$ .5) DO D
2. If Commercial project,what is the proposed use:
3. Are there any structures not shown on the plot plan? YES 41, xplain:
4. Are there any easements on the property? YES 0
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 't(No�
SIGNATURE: DATE: -
Accessory Structure Application Revised February 2019