application aliffr ke
•
Office Use Only
ACCESSORY STRUCTURE
\ 1 PERMIT APPLICATION Permit#: -PO• bA`��- 2-0
Town of Qccnsbury Permit Fee:$
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net Invoice#:
Project Location:
Bret 5
Tax Map ID#: .c D l Subdivision Name:
CONTACT INFORMATION:
•
• Applicant:
Name(s): 2-
Mailing Address, C/S/Z: 3S 1 N ((ow Quper-Ans-ir�
Cell Phone: (516 ) 9 27 Land Line: ( )
Email: --cs(Z111667d;L
• Primary Owner(s):
Name(s): Srfv.e_
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: ( )
Email:
heck 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:
Cell Phone: ( ) Land Line: ( )
Email:
Accessory Structure Application Revised February 2019
1
PROJECT INFORMATION: r ,
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
Detached Garage _Boathouse(with or w/o sundeck) 3-Season Porch
Other(description: pe(` `E}
SQUARE FOOTAGE OF STRUCTURE:
1st floor: a
2"d floor:
Total square feet: I 1 I. 7)
Pl
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$ Q e&r•a,Ap- :, F � �� ch' S%-, 4r�
2. If Commercial project,what is the proposed use:
3. Are there any structures not shown on the plot plan? YES 610 xplain:
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 pr. o issuan of a certificate of occupancy.
I have read and agre o the above:
PRINT NAME: l5
SIGNATURE: DATE: 1 ✓I - jr
Accessory Structure Application
Revised February 2019