application Office Use Only
J ACCESSORY STRUCTURE
Permit#: & -2i3\01
PERMIT APPLICATION
Town ofQcccnsbuty Permit Fee: $ 125
742 Bay Road,Queensbury,NY 12804 �L
P:518-761-8256 www.queensburv.net Invoice#: 11
b.
Project Location: 2.. 9-
Tax Map ID #: 7Sj(c (s1 -'1 — 721 Subdivision Name:
CONTACT INFORMATION:
• Applicant:
Name(s): v in S L 0 R ,Jc
Mailing Address, C/S/Z: _r rJ/1-/ 6/61 - co P-f ►- / /% Foil
Cell Phone: ( ) /2, 3 6 8- 7 Land Line: ( 7 T ) 9 YS-'03g1
Email: '(oI'1 . Ek.s'z y 6°J97,Jt t�
• Primary Owner(s):
Name(s): Ate/ s' Ley/
Mailing Address, C/S/Z: ®2..S— -7= NSO / Qt/i C3L112 fa/led L\7P
Cell Phone: ( ,s 9 ) Land Line: ( 51 ) r) £/. 9 ?/
Email: Je ccAr (/11/A16 tesok
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:
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: ( ) 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
WOR ASS:
eck, Open Porch Solar Panels(w/o rafter upgrades) Carport Cell Tower
Shed Pavilion, Pole Barn, Canopy Doc _Gazebo
Detached Garage Boathouse (with or w/o sundeck) 3-Season Porch
Other(description:
SQUARE FOOTAGE OF STRUCTURE:
1st floor: ``7T
2nd floor:
Total square feet: � - �c j
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ DDO .�
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: DATE:
Accessory Structure Application Revised February 2019