application _ t.
Office Use Only
r'M : ACCESSORY STRUCTURE 1
�. ,,x Permit#: P.61 "ocr�l"5' 20 n
: PERMIT APPLICATION
Town of Queensbury
Permit Fee:$
0�
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensburv.net Invoice#: Z
Project Location: TJ iv\ eiy,, .
Tax Map ID #: 2' . `p _ 12. \ 11- Subdivision Name:
CONTACT INFORMATION:
• Applicant:
Name(s): �io5��....�,ry a�� �-a .Vi �us� )"e
Mailing Address, C/S/Z: Pn gox )7y Glev-r .a ; 14y I .0
Cell Phone: ( albs ) 3 t 7- 3'-3V Land Line: ( ) 666 - 90 5 f
Email: ctg�»:N a(
• Primary Owner(s):
Name(s): Vret-‘1\11 e"S‘cTe-i
Mailing Address, C/S/Z: Pp sox' `A7N, Ueoe-AAke , / 1•7,T7e)
Cell Phone: ( 5%93 ) 36°i- ' S3V Land Line: ( 5 J$ ) G54-90C%
Email: art.;Vse p clot .L0-7
❑ Check if all work will be performed by property owner only
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): 5 `oLiv, is if‘.> ". A ha (€ of,e Sin. Co Arc[. ►v;e
Contractor Trade: l r: r e,�-}-i, — 9 a t,je- 1��� , et--
Mailing Address, C/S/Z: /30:1- cittd r`/( j, W,V (2 'g it
Cell Phone: ( ) Land Line: (1, ) -i 5'-- 7 Y 5 9
Email: .5kj,,vn r I44> Q a ie cR , G r� e ,�►'�.
**List all additiEnal contractors on the back of this form
• Architect(s)/Engineer(s): 9 ;
Business Name: 11��
Contact Name(s): Yet ' U U 6 2O2 1 I
Mailing Address, C/S/Z: ..11111111_
Cell Phone: ( ) Land Line: ( BUILD,NC;R. LF Y
Email:
Contact Person for Building & Code Compliance: Carci-
Cell Cell Phone: ( ) Land Line: ( )
Email:
Accessory Structure•Application Revised January 2020
• 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 X Boathouse (with or w/o sundeck) _3-Season Porch
Other(description:
SQUARE FOOTAGE OF STRUCTURE:
1st floor:
•
2nd floor:
Total square feet: _
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$ / j,c'c b 6
2. If Commercial project,what is the proposed use:
3. Are there any structures not shown on the plot plan? YES Explain:
4. Are there any easements on the property? YES QFp
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: ���� �J, 6 u5,A4e t'
SIGNATURE: 69, 0,6iv 4a DATE: W CJ W-2o
Accessory Structure Application Revised January 2020