applicationy
Office Use Only
010
ACCESSORY STRUCTURE
PERMIT APPLICATION Permit#: A S-(-_ v`-{l(o`ZD/�
Town of Queensbury 'T
742 Bay Road,Queensbury,NY 12804 E C ~f
P:518-761-8256 www.queensbury.net D Irivuit. tp7
Project Location: q1a R� �� �,, JUN 17 2019
TOWN OF QUEENSBURY
Tax Map ID #: 990,104-\ 3a I B1SUbdt s1d N e:
CONTACT INFORMATION:
• Applicant:
Name(s): sse (
Mailing Address, C/S/Z: '33%., `I�LC ( s1, 1 dX-oct v ) cA.,4
Cell Phone: ( st k ) l°�b'� 0154 Land Line: ( ) cAJA: _
Email: \A 5 OoCTos'LA YR C
• Primary Owner(s):
Name(s): V sRE?('D
Mailing Address, C/S/Z: cri R;6cso k\ , Q.,e_o^stlori3 Ny: icnot{
Cell Phone: ( SN ) 1'i$- oq 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): --kUssd Ac5 0rc74'.S2
Contractor Trade: .0'),)S-,),,k zzo,..)
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: 2tSce.1l �►o'4`k-
Cell Phone: ( Sid- ) 0'7 S'( Land Line: (
Email: \-1rliSe_ e%�cLc-c\.,SS ® 'ycf how COM
Accessory Structure Application Revised February 2019
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PROJECT INFORMATION:
TYPE: Commercial V 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: C., 5
2"d floor:
Total square feet: (o€---C
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ , 0 00
2. If Commercial project, what is the proposed use:
3. Are there any structures not shown on the plot plan? YES NO Explain: t..)
4. Are there any easements on the property? YES 6_30,)
DECLARATION:
I. 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: � 355e,1,1 0 C'_
SIGNATURE: J �.- DATE: I S "
Accessory Structure Application Revised February 2019