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application L y . Office Use Only ACCESSORY STRUCTURE PERMIT APPLICATION Permit#: 4\3T— `n�cj 2 - ZO\� Iowa of Oyeens elr}' Permit Fee:$ 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.queensbury.net Invoice#: 1 to£+ \e Project Location: 1 ritta keWCoc( Tax Map ID #: t !1 4 Subdivision Name:111U (,CAN oQ d CONTACT INFORMATION: • Applicant: Name(s): V-00-0X\ &I L S-C49 p-C , MailingAddress, C/S/Z: (Vl ptWoc bY' Qv)MSbUrj IVLl 1Z8oy Cell Phone: ( 61"S ) w 3 w q, 23 Land Line: ( Email: 1<c)UIc 422 , mac t C'Q • Primary Owner(s): Name(s): c5 0�X1�>• Mailing Address, C/S/Z: Cell Phone: 1 ) 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): N IA 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: N Contact Name(s): Mailing Address, C/S/Z: Cell Phone: { ) Land Line: ( Email: �/ Contact Person for Building & Code Compliance: KCt reh Soiscp of Cell Phone: {51i ) 63 h 1233 Land Line: ( ) Email: K�U 1 Sl e ft.e (NAG • COY►', Accessory Structure Application Revised February 2019 PROJECT INFORMATION: TYPE: Commercial R 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: -A.--45.8 2nd floor: Total square feet: 451 ADDITIONAL PROJECT INFORMATION: 1. Estimated Cost of Construction: $ I S6D D 2. If Commercial project,what is the proposed use: /U 3. Are there any structures not shown on the plot plan? NO Explain: 6 IAA +o ("C&tr off' tC1 Polo 4. Are there any easements on the property? YES J 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: ' 1Urn i‘eppe. e, SIGNATURE: 4f,U114 6DATE: le(fi/M Accessory Structure Application Revised February 2019