application ffice Use Only
I. >a, ACCESS ,E rOcifinflEY
PERMIT PLI I ermit#: A 5►" 3 -
Q.. ;: A 19
C Town of vicensbu 2019 � Permit Fee: $ ,� �.J ,
742 Bay Road,Queensbury,NY 1280/11
P:518-761-8256 www. ueensbur 'netTOWN OF QUEENSBURY Invoice#: L/L(7
_ M BUILDING&CODES
Project Location: 3 -I 1 E 0 CDVTE AJ -ROC)
Tax Map ID #: I Subdivision Name: t V r --S
Nt s
CONTACT INFORMATION:
• Applicant: nn
Name(s): icy f tN c---A"S
Mailing Address, C/S/Z: E-ADO / -7
Cell Phone: ( S ( B ) 3 " 60 I I Land Line: (
Email: pr 01,FL--C CC-0 LA () . C- )A
• Primary Owner(s):
Name(s): e„ AS A(3 n,-✓ �,.
Mailing Address, C/S/Z:
Cell Phone: ( ) 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):
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: C ,t. Imo\\ c L, M�
Contact Name(s): TOM K 1
Mailing Address, C/S/Z: e:43 C i Nu-LS T o m c PA PM
Cell Phone: ( ; r ) 1j 2-- v(0) Land Line: (
Email:
Contact Person for Building & Code Compliance:
Cell Phone: ( ) Land Line: _(
Email:
Accessory Structure Application Revised February 2019
PROJECT INFORMATION:
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:
2nd floor:
Total square feet:
5 3
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ (0 t O 00
2. If Commercial project,what is the proposed use:
3. Are there any structures not shown on the plot plan? YES NO 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: •
SIGNATURE: > L C. A Ai 1) cO Al DATE: 17
Accessory Structure Application Revised February 2019