application ,�- Office Use Only
ACCESSORY STRUCTURE . ® <
Permit#: � )
PERMIT APPLICATION
Town of Queensbury Permit Fee: $ 1 2_r-D
742 Bay Road,Queensbury,NY 12804 y,
P: 518-761-8256 www.queensburv.net Invoice#: 11515
Project Location: �� ae�Ns tee LL uqus;A27
Tax Map ID #: 7.31(-3.0 30ge ^ I 7 c Subdivision Name: ,c i• . `` C�. _�. _.
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CONTACT INFORMATION: e I , 3 11
i11 APR 242019 ij',d
• Applicant: .�M
Name(s): TOWN OF OLJEENSBURY
Mailing Address, C/S/Z:
Cell Phone: ( ) `/ Land Line: ( ) Z- i
Email: N°s l A..ee1,Q Q. orvaL;t.Co r\
• Primary Owner(s):
Name(s): -\
Mailing Address, C/S/Z: � titskc o rikt vc t �s�;��y, N y '1
Cell Phone: (Sas ) �a� - �L( Land Line: ( ��� ) SU2-" i ` t L(
Email: ^, e_ eary\c,: corY.
❑ Check if all work will be performed by homeowner only
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): `(LC) CO f\-) i 1Ua_C-T-t. - 1 N\L-7-s toLL-���
Contractor Trade: ->t--c_tx r=,
Mailing Address, C/S/Z: ec-3G Zo�� -l-Clb r ki V I Z° 2-6)
Cell Phone: ( ) Land Line: ( S / ) 7 2 Z
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 Compliance: 1)0tc_eArtr
Cell Phone: ( ) Land Line: (
Email:
Accessory Structure Application Revised February 2019
PROJECT INFORMATION:
TYPE: Commercial X 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 2c) S
2'floor:
Total square feet: `2-2O S F
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ /�, CUU
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: A\NJ N\ L‘4- 1 �r
SIGNATURE: �. L/ DATE: q/Igq/40/9
Accessory Structure Application Revised February 2019