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application Office Use Only 4101111016k� Permit#: Sr—CUP ( ZU( �' ACCESSORY STRUCTURE er PERMIT APPLICATION Permit Fee:-$ Town of C uccttsbury � 742 Bay Road,Queensbury,NY 12804 Invoice#: 0 c l —7 & P:518-761-8256 www.queensbury,net OCT 23 2018 Project Location: ‘© Tax Map ID #: 1::ke ,� _ \� �+). Subdivision Name: CONTACT INFORMATION: • Applicant: Name(s): � � Mailing Address, C/S/Z: ' VeN ca \ ` c . ,q,t, � \4-1 QM Cell Phone: ( >, ) k-- Land Line: (RS'`t ) Email: V\ Ott:\A. • Primary Owner(s): Name(s): \\Qv Ica \ \ Mailing Address, C/S/Z: ' \+C,(N;,\\_ '\r U �,h.;,� \J ( r' ` 'I , Cell Phone: ( s9 ) \%'\_ 'W .c Land Line: (C t , ) l \ Email: :` ,'��: � � ��, , • Contractor(s): Business Name: tk‘c iof Contact Name(s). Mailing Address, C/S/Z: Cell Phone: ( ) Land Line: ( ) Email: • 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: C\f\ q..-`\�� ��ca Cell Phone: ( `S\\ ) k� �a� e Land Line: j ) OUV L Email: ifJ 1thi Town of Queensbury Building&Code Enforcement Accessory Structure Application Revised April 2017 A A 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: ,v`sk 2"d floor: Total square feet: ,`k.v. ADDITIONAL PROJECT INFORMATION: 1. Estimated Cost of Construction: $ e ,CC'•-- -- 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: rif L 44 7-) ie; SIGNATURE: ,�� DATE: fC�,.l-�,1; { Town of Queensbury Building&Code Enforcement Accessory Structure Application Revised April 2017