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AST-0017-2020
Pe UETUR ice Use Only—I AAline:AGT 0017-2 PERMIT APPLICATION |Pent #*—A2E rEJAN142020JpimitFee:$B12 .O0 Anvoice #:_23)O Town of Queensbury al742BayRoad,Queensbury,NY 12804 | P:518-761-8256 www.queensbury.net Project Location:__\\thoness the cs Tax Map ID #:BOS AB —\-23 Subdivision Name:_Gedford Close CONTACT INFORMATION: ©Applicant: Name(s):ved reels wa, Mailing Address,C/s/z:__\Were ottosoPXCarnsboryWl(Bot Cell Phone:_(St®)__“e\-27120 Land Line:_() Email:Seed @ qacden becene com +Primary Owner(s): Name(s):Sane Mailing Address,C/S/Z: Cell Phone:_()Land Line:_() Email: [Check if all work will be performed by homeowner only *Contractor(s):Workers’Comp documentation must be submitted with this application Contractor Name(s): Contractor Trade: Mailing Address,C/S/Z: Cell Phone:_()Land Line:_(). Email: **List all additional contractors on the back of this form ©Architect(s)/Engineer(s): Business Name: Contact Name(s): Mailing Address,C/S/Z: Cell Phone:_().Land Line:_() Email: Contact Person for Building &Code Compliance:pol col Cell Phone:_()Land , Email:, Revised February 2019 PROJECT INFORMATION: TYPE:____Commercial J Residential WORK CLASS: _Deck,Open Porch __Solar Panels (w/o rafter upgrades)__Carport __Cell Tower __Shed __Pavilion,Pole Barn,Canopy __Dock __Gazebo Aoeaciea Garage __Boathouse (with or w/o sundeck)__3-Season Porch __Other (description:) SQUARE FOOTAGE OF STRUCTURE: Ast floor:__@2A 24floor:__AXe Total square feet:_\,O40 ADDITIONAL PROJECT INFORMATION: \1.e4%1.Estimated Cost of Construction:$. 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 DECLARATION: 1,acknowledge that no construction shall be commenced prior to issuance of a valid permit and will be completed within a 12 month period. 2.Ifthework is not completed by the 1 year expiration date the permit may be renewed,subject to fees and department approval. 3.Icertify 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.|acknowledge that prior to occupying the facilities proposed |,or my agents,will obtain a certificate of occupancy. 5.lalso understand that I/we are required to provide an as-built survey by alicensed land surveyor ofall newly constructed facilities prior to issuance of acertificate of occupancy. I have read and agree to the above: PRINT NAME:Fed sTroetsha SIGNATURE:4 CZ Cc DATE:ils |e Saeassinhi Structure Sostcation Revised February 2019