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applicationOffice Use Only ACCESSORY STRUCTURE on.AST 9220 -2020PERMITAPPLICATIONPermits Tin f Queene eS - 742 Bay Road,Queensbury,NY 12804 Pere Fear 0P:518-761-8256 www.queensbury.net Invoice #:_LOS Project Location:9BaetilaedDr Tax Map 1D #:_79@-\-Bal Subdivision Name: WEOCE MIE)LACE, CONTACT INFORMATION: ©Applicant: Name(s):._\ Mailing Address,C/s/2:__\__oc\ALASO OB.Lave GepRGE WX v2BH5~ Cell Phone:(618 )_Bol W223"Land Line:_(51%)_“1AB-le21Email:__afo4 @ \edge Wied.Coed +Primary Owner(s): Name(s):A2amMe Mailing Address,C/S/Z: Cell Phone:(HIB)Blo\=AZ2AA land Line:(57®)_“148 -blo2 Email:onc if all work will be performed by homeowner only Contractor(s):Workers’Comp documentation must be submitted with this application Contractor Name(s):Tors tr.WoerkeS Copsr Co ral Contractor Trade:Bw OER Mailing Address,C/S/Z:i G Cell Phone:_(s5\B).-~ Land Line:(SVR)=Talo Email:nh ae@ iaigedien.Cas **List all additional corttactors 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:(512)Biol 2 34 land Line:(5B)TIR-bbb7 1 \eEmail:_1wtoA @ is NOa CO HY Accessory Structure Applition Revised Februsy 2019, PROJECT INFORMATIO! TYPE:Commercial V_Residential WORK CLASS: __Deck,Open Porch __Solar Panels (w/o rafter upgrades)__Carport __Cell Tower _Shed __Pavilion,Pole Barn,Canopy __Dock __Gazebo petached Garage __Boathouse (with or w/o sundeck)__3-Season Porch __Other (description:) SQUARE FOOTAGE OF STRUCTURE: Ast floor:25 2 2"floor: Total square feet:_“AG Z. ADDITIONAL PROJECT INFORMATION: 2.if Commercial project,what is the proposed use: 3.Are there any structures not shown on the plot plan?YES CoA sain: 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. If the work is not completed by the 1 year expiration date the permit may be renewed,subject to fees and department approval.|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. |acknowledge that prior to occupying the facilities proposed |,or my agents,will obtain a certificate of occupancy. 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 acertificate of occupancy. Ihave read and agree to the above: PRINT NAME x GWE?wa WL.J-dd-J0‘SIGNATURE:a 4 DATE:__ ocean StroctreApplistion Revsed February 2018,