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Office Use Only ACCESSORY STRUCTURE PERMIT APPLICATION Town of Queensbury 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.queensbury.net Project Location:56 Ql West Mtn,2b. 201 Permit Fee:$_BOA Invoice #:_22.2. Tax MapID#:__3:3%.-1-76 Subdivision Name:aeCONTACTINFORMATION:RECEIVE ©Applicant:.7 ) Name(s):Mark Ber ling,l NOV 20 2019 Mailing Address,C/S/z:_S Did Wet Mn.RU |TOWN OF QUEENSeoRy Cell Phone:_(_$(%)746-0797%Land Line:_(-——CUEDING &copes: Email:mbcMintO gmaile tom «Primary Owner(s):| Name(s):[lavic 4 Gwen Bri [Mins, Mailing Address,C/S/Z:__S&Old West mtu.RE Cell Phone:_(S1%)746-077 Land Line:_() Email:_rabrillins 1 @ gmail.comJJ ‘DAcheck 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: 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: /V lye Contact Person for Building &Code Compliance:“ar &Bri (\ny Cell Phone:_(G'S )71¢6~O77 Land Line:_() Email:_spber thing Le gee (com Revised Febcuary 2018 PROJECT INFORMATION: TYPE:____.Commercial _K Residential WORK CLASS: __Deck,Open Porch ___Solar Panels (w/o rafter upgrades)__Carport __Cell Tower __Shed __Pavilion,Pole Barn,Canopy __Dock ___Gazebo XK detached Garage __Boathouse (with or w/o sundeck)__3-Season Porch )__Other (description: SQUARE FOOTAGE OF STRUCTURE: Ast floor: 2 floor: Total square feet:_/2%© ADDITIONAL PROJECT INFORMATION: ated Cost of Construction:$_/9,009. 2.If Commercial project,what is the proposed use: 1.Esti 3.Are there any structures not shown on the plot plan?YES NO Explai 4.Are there any easements on the property?Yes No. DECLARATION: V1.|acknowledge that no construction shall be commenced prior to issuance of a valid permit and will be completed within a 12 month period. V2.Ifthework is not completed by the 1 year expiration date the permit may be renewed,subject to fees and department approval. V3.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. V 4.|acknowledge that prior to occupying the facilities proposed I,or my agents,will obtain a certificate of occupancy.5.also understand that IAve are required to provide an as-built survey by alicensed land surveyor of all newly constructed facilities prior to issuance of acertificate of occupancy. Ihave read and agree to the above: PRINT NAME: —ork Belg‘SIGNATURE:Fc LZ DATE:N\21|2e09 Accessory Structure Aeeliestion Revised February 201