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Office Use On! ACCESS feeetve mit CDS “200 | PERMIT 4 pp ~Tome of seer JUN 22 2023||[Permit ree:s_7500 oe | invoice #:_207 (0 742 Bay Road,Queensbury,NY 12804|||| F TOWN OF QUE! P:518-761-8256 www.queensbury.nt .BUILDING&GODES Project Location:35 War S £J Tax Map ID #:$2340)_309,1 -1-39 Subdivision Name: CONTACT INFORMATION: .licant: Name(s):CAaY Landolt Mailing Address,C/S/Z:_28 Wayw St Cueevthaag, Cell Phone:(siy )_321 4244 landline?(572)772-722)Wid) Email:_CGAry @ Lupeessive Lypzeints on +Primary Owner(s)\S 42> Name(s}:wey tardyll Mailing Address,C/S/2:_2%maw S- Guvewshe. CellPhone:(s(2 )_22)Y277 Land Line:_(s/2_)772 722/ Email:_Geay @ Fayncyive trpaits corn O Check if all work will be performed by homeowner only — ©Contractor(s):Workers’Comp documentation must be submitted with this application Contractor Name(s):T@4derhand Auildeg +Bonedeling Contractor Trade:Pliny ¢Senpdeling Mailing Address,C/S/Z:_]-Siavet Glew;Falls CellPhone:(S72)36//4ge Land Line:(572)295°4/7)(Fae Email:_yn Bouch 2052 Yoho cy**List all additional contractors on the back of this form ©Architect(s)/Engineer(s): Business Name:SAme as Covthac toContactName(s): Mailing Address,C/S/Z: Cell Phone:_()Land Line:_() Email: Contact Person for Building &Code Compliance:Arphic ays Cell Phone:_()Land Lin Email: Aecetory Suture Appleton Revised February 2019, PROJECT INFORMATION: TYPE:X.commercial ____Residential WORK CLASS: _Z Deck,Open Porch __Solar Panels (w/o rafter upgrades)__Carport __cell Tower __shed ___Pavilion,Pole Barn,Canopy __Dock __Gazebo __Detached Garage ___Boathouse (with or w/o sundeck)___.3-Season PorchYother(description:Steps,lavdin ) SQUARE FOOTAGE OF STRUCTURE:/V/lor Ast floor: 2"floor: Total square feet: ADDITIONAL PRO.INF 1.Estimated Cost of Construction:$__“,SOO If Commercial project,what is the proposed use:Leaain/Aephce Styps,banSiry,anny,Ewttanccuthy 3.Are there any structures not shown on the plot plan?YES (9 Explain: x >Are there any easements on the property?ves No DECLARATION: 1.1 acknowledge that no construction shall be commenced prior to issuance of a 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.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 |(ve are required to provide an as-built survey by a licensed land surveyor ofall newly constructed facilities prior to issuance of acertificate of occupancy. Ihave read and agree to the above: PRINT NAME:Gay ariel SIGNATURE:tig LA -DATE:G Le2o<—— Accessory Structure Appltion Revised February 2019,