application Office Use Only
ACCESSORY STRUCTURE
`�'__ �1 PERMIT APPLICATION Permit#: 4 Y ��7 ~®�® I
Town of Queensbury Permit Fee: $ 1 Ct?v
--
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net Invoice#: (364
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31 q 1
Project Location: ON iti/9� eg .9,441—
Tax Map ID #: 3O r HD- Subdivision Name: 56f)/2 0 (-lose
CONTACT INFORMATION:
• Applican
Name(s): e/ ,24 / 11n-
Mailing Address, C/S/Z: 3/ % v ,-„6...
Cell Phone: (37 ) 7q•d'-- ® i 6 Land Line: ( ,c/ ) 79,3- 67 '7 ( i2k
Email: a 14 9, e k/e'--fc. a)-,".
• Primary Owner(s): �}—
Name(s): P`` c �\
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: ( )
Email:
Check if all work will be performed by homeowner only
• Contractor(s): Wor ers' Comp documentation must be submitted with this application
Contractor Name(s): cl ei-p,
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:
Contact Person for Building & Code Com liance: / 'f/ 47 /2Bt'f
p �
Cell Phone: ( 3 f ) 79A--029 ' Land Line: (3Y8 ) 79:3- 671 7
Email:
Accessory Structure Application Revised February 2019
a. .
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: /
2nd floor:
Total square feet: / -
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ ✓o9-
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
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:gbwg.f9
PRINT NAME:
SIGNATURE: !,% /1 DATE:
Accessory Structure Application Revised February 2019