application ACCESSORY STRUCTURE y D� .ZQ��
PERMIT APPLICATION Permit#:_
Town of Queensbury
742 Bay Road,Queensbury,NY 12804 Permit Fee: $ ��
P:518-761-8256 www.queensbury.net Invoice#: )5°g
Project Location: 13 S vc.4 A-/oP as
Tax Map ID#: SP>L 301. 4 - 2 -5 Subdivision Name:
CONTACT INFORMATION:
• Applicant: /
Name(s): LEE l--io,2oa t ,d
1 Mailing Address, C/S/Z: 1434 120e, �' , iL(o/2+a.ov , ' Y 12.92-8
Cell Phone: ( el8 ) Goc-. SoGe Land Line: ( CIS ) ')SS . d2o7
Email: L i=E 1-1e -.i r,.cc. i 464 ear ILA,c. „ ca A.-e
• Primary Owner(s):
Name(s): J0 aiJ FC12ex24L0
Mailing Address, C/S/Z: l 3 S 'r C4 -eo,z..
Cell Phone: J S I8 )Rrj; .. . 75?S Land Line: ( 61 ) 7,8, ins
Email:
El Check if all work will be performed by homeowner only
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): o,2.-4 .44 L '..s�•i
Contractor Trade: e-P5v14.17 T-24. ;b2
Mailing Address, C/S/Z: 148 4 ll of E 9 02�0� , .,.1. 1 282&
Cell Phone: ( 51F, ) Land Line: ( 51S ) 9 33. c2s7
Email: Lae. l4&4 e ,C
**List all additional contractors on the back of this form
1 • Architect(s)/Engineer(s):
rECEoWE
Business Name: NA 1
Contact Name(s): V
Mailing Address, C/S/Z: OWN OF QUEENSBURYDUfLDING & CODES
Cell Phone: ( ) Land Line: (
Email:
Contact Person for Building & Code Compliance: L IE� j,. o.�,,.r, .� s.
Cell Phone: (.(s ) 5 64. c. Land Line: ( SI S ) 7g v. oZo,
Email:_ l../0,2.-4,-i4 !4a4 C G A-!d •L . C s
Accessory Structure Application Revised February 2019
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:
2nd floor:
Total square feet: 32e,
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$ I m, 060
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 09)
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: L 66- L I �•-t F
SIGNATURE: DATE: 9.
Accessory Structure Application Revised February 2019
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