application Office Use Only
Permit#: �v� m9 Flo` 2O 5
eL, 4 e ACCESSORY STRUCTURE
M.
•- `� ; .-. PERMIT APPLICATION Permit Fee:$
Town of Queensbury
742 Bay Road,Queensbury,NY 12804 Invoice#:
P:518-761-8256 www.queensbury.net
Project Location: 64 G A - n S4-ree k een'.l r 1 N4 0.504 epn-edi64J 1/9.01
Tax Map ID#: 30q,lU— I 10 Subdivision Name:
CONTACT INFORMATION:
• Applicant:
Name(s): Co& Atmeirict ( Q?eX coia.r rower)
Mailing Address, C/S/Z: Main :4-ree+, (UeendaurM NNi 923c$
Cell Phone: ( ) Land Line: ( SIR ) to -z-n6
Email: (hbmelrkJ< phert )o0h A Corn chatrteir cJ C afexcolar rawer scam
• Primary Owner(s):
Name(s): apex De arse i-.I-C
Mailing Address, C/S/Z: gya ,e a cd, r
Cell Phone: ( ) Land Line: ( Sic; ) 7o zi
Email:
• Contractor(s):
Business Name: cAr,>< bemar;e LLC
Contact Name(s): Same ac aLlue
Mailing Address, C/S/Z: came as 46oare
Cell Phone: ( ) Land Line: ( )
Email:
• Architect(s)/Engineer(s): C�y
Business Name: in 6 u u '4 n 9(118
II "i G J4". v .e xry
Contact Name(s): r �L
Mailing Address, C/S/Z: r r= ° p ,,'<.m'Et_R
K&-ri''.=,ems
Cell Phone: ( ) Land Line: (
Email:
Contact Person for Building&Code Compliance: cnAle. a ' c L ve
Cell Phone: ( ) Land Line: ( )
Email:
•
Town of Queensbury Building&Code Enforcement Accessory Structure Application Revised April 2017
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: - -
_
- - - - 2'floor:
Total square feet: '22
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$ -
2. If Commercial project,what is the proposed use: Care Offke Caesfor-1-
3. Are there any structures not shown on the plot plan? YES 0 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: CoAta t4tm&lrT En l apex Sratou- r'aw r'
SIGNATURE: .", N d4.44k DATE: 11lei I
Town of Queensbury Building&Code Enforcement AccessoryStructure Application Revis
ed April 2017