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Office Use Only ACCESSORY STRUCTURE it 1-022 -QPERMITAPPLICATIONPermit12-20U Town of Caeentery 742 Bay Road,Queensbury,NY 12804 Permit Fee:$4P:518-761-8256 www.queensbury.net Invoice #:_260 Project Location:/6/ALGeNGUWTRie_ TaxMapip#:301.13 “2-657 Subdivision Name:_|YES Woo CONTACT INFORMATION: e Applicant: Name(s):Loki +Samer Pi TCHEAAUE Mailing Address,C/S/Z:_/4 A4éoWauw hive Qucensexay,NI (20H Cell Phone:(5/3 _)GAS-ROSS Land Line:_(). Email:Jhpiteneeanre @_WAros com +Primary Owner(s): Name(s):LoRl +Samuer “Pitcnekacee Mailing Address,C/S/Z:_/6 Arco ®@uw peve,Queensaury,NY (2704 Cell Phone:_(57%)925-2053 Land Line:_() Email:___lhpricteealie @_Yattoo,corn check if all work will be performed by homeowner only ©Contractor(s):Workers’Cot locumentation must be submitted Contractor Name(s):Cavdunltme [rR Contractor Trade:—Mailing Address,C/S/Z:aia Cell Phone:_(),Land Line:(|"" Email:|TOWN OF **List all additional contractors on the back of this form — Contact Name(s): Mailing Address,C/S/Z: Cell Phone:_()Land Line:_() Email: Contact Person for Building &Code Compliance: Cell Phone:_()Land Line: Email: ek,PROJECT INFORMATION: TYPE:____Commercial 2X Residential WORK CLASS: __Deck,Open Porch __Solar Panels (w/o rafter upgrades)__Carport __Cell TowerXshed__Pavilion,Pole Barn,Canopy __Dock:__Gazebo ___Detached Garage __Boathouse (with or w/o sundeck)__3-Season Porch ___Other (description:) SQUARE FOOTAGE OF STRUCTURE: astfloor:__/“78 ex” 2 floor:W/A Total square feet:__/70. ADDITIONALPROJECT INFORMATION:1.Estimated Costor Construction:S256.Garden Time SHed +Be Deliered V/A 3.Are there any structures not shown on the plot plan?YES—NO/Explain: 2.If Commercial project,what is the proposed u! 4,Are there any easements on the property?YES wo”) DEC!TIO! 1.Lacknowledge that no construction shall be commenced prior t completed within a 12 month period. ssuance of a valid permit and will be 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 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 [Ave are required to provide anas-built survey by alicensed land surveyor of all newly constructed facilities prior to issuance of a certificate of occupancy. 'have read and agree to the above: prInTNAME:Lae B.Pitewewrue BF Samuel3Ptehewatle SIGNATURE:La ‘tell pate:_5 29-20pm)Plu Ce,