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Office Use Only ACCESSORY STRUCTURE vermin PST=4222-.“9222-2920PERMITAPPLICATIONerm 5TonofCenti -742 Bay Road,Queensbury,NY 12804 Permit Fee:a:518-761-8256 www.qucensbury.net Invoice #:22 VS Project Location:_/5°Berry Deive TaxMapID#:5 23400 1.84./2-/=1.)5°subdivision Name: CONTACT INFORMATION: ©Applicant: Name(s):Thoma Kein Mailing Address,C/S/Z:_iS Rhervy Deive Queensbury NY i2¢o4 Cell Phone:_(S18 )adi 19 33 Land Line:_() Email:haren SI ENY COO.66s Com +PrimaryOwner(s): Name(s):Thomas Edward kK ing Mailing Address,C/S/Z:_15 Berry DR Queensbury VY 12604 Cell Phone:_(5-/f )2a1 |33 Land Line:_(), Email:_shacma ©%@ ny cap.rr.(om O Check if all work will be performed by homeowner only ©Contractor(s):Workers’Comp documentation must be submitted with this application Contractor Name(s):hed Stop Contractor Trade: Mailing Address,C/S/2:__@&S54 Stale Route +Fort Ann NY 1abaT Cell Phone:_()land Line:(S12)639 3055Email_Shed sto pi ©Yahoo,corm *#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:BUILDING &CODES Contact Person for Building &Code Compliance:\ic Cell Phone:_()Land Line:_() Email: accessory Struct Ropestion Reve February 208 i.PROJECT INFORMATION: TYPE:____Commercial _v_Residential WORK CLASS: ___Deck,Open Porch _Solar Panels (w/o rafter upgrades)__Carport _Cell Tower L Shed 1axat __Pavilion,Pole Barn,Canopy __Dock __Gazebo __Detached Garage ___Boathouse (with or w/o sundeck)__3-Season Porch ___Other (description:) SQUARE FOOTAGE OF STRUCTURE: Ast floor:_33%AE 2"floor: Total square feet:S3te AS * ADDITIONAL PROJECT INFORMATION: 1.Estimated Cost of Construction:$L000 2.If Commercial project,what is the proposed use: 3.Are there any structures not shown onthe plot plan?YES (0)Explain: 4.Are there any easements on the property?Yes &) DECLARATION: 1.lL acknowledge that no construction shall be commenced prior to issuance ofa 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.I certify that the application,plans and supporting materials are a true and complete statement and/or descri 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 I,or my agents,will obtain a certificate of occupancy. 5.lalsounderstand that [Ave are required to provide an as-built survey bya licensed land surveyor of all newly constructed facilities prior to issuance of a certificate of occupancy. \have read and agree to the above: rn eae Tbs kk aé.——‘ SIGNATURE:é nea pate:5/22)20 Accessory trustre Appleton Revd February 2038