application /1)
Office Use Only
ACCESSORY STRUCTURE
Permit#: r— 24;15 • 2-Q31-0
PERMIT APPLICATION
Town of Quccnsbury
742 Bay Road,Queensbury,NY 12804 Permit Fee:$ � . Ot7
P:518-761-8256 www.queensbury.net Invoice#: 2 (0 Q Lt
Project Location: 3LS Lu.2 s e ne_
Tax Map ID #: 5'21400 3024 -if! ' 99 Subdivision Name:
CONTACT INFORMATION:
• Applicant:
Name(s): e.114 Ca.(ro f Ftt.c -1.s 1 o c1tier
Mailing Address, C/S/Z: 2 , is L u,z.arn Rol / G?keens 614,ry WV l:zgoiP
Cell Phone: (-i' ) 7 7� 3 2...3 Land Line: (
Email: C cite.he rocher Yahoo. corn j iwb yakoa ^ Co.wc
• Primary Owner(s):
Name(s): Soft/me`-II l Caro !" 1=u,cha l ocrn.ev
Mailing Address, C/S/Z: Sa.w.$ /la . Rbove-.
Cell Phone: ( ) Sa.w.e 4c A he o a Land Line: (_ )
Email: e- as a.bo
❑ Check if all work will be performed by homeowner only
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): Dan Mb€.r i
Contractor Trade: riew 14014t•es , Adcli1'rva ) Re rKvcle n
sci
Mailing Address, C/S/Z: '/7 J ap per' Shexnman Rage, j (Lteerts bwor NY 'ZT O
Cell Phone: ( ) 77 9 SS' 1 9 Land Line: ( )
PRIM-. evr:C\rot c..TO v- S fs') k Q-wk 0;0 grit
**List all additional contractors on the back 6f this form c rE g �r [
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• Architect(s)/Engineer(s): N 12 2020
Business Name:
Contact Name(s): TO\NN OF QU ENSBURY�
Mailing Address, C/S/Z: LiUIL®6N 84 eUumS
Cell Phone: ( ) Land Line: (
Email:
Contact Person for Building & Code Compliance:
Cell Phone: ( ) Land Line: (
Email:
Accessory Structure Application Revised February 2019
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 —Boathouse (with or w/o sundeck) a 1/3-Season Porch /300 V 7
Other(description: ) '3 l 41,4 l $4 area I- o 01►6
6Y 8 c Own- f ra k.,
SQUARE FOOTAGE OF STRUCTURE: v
1st floor: ii2O
2nd floor:
4
Total square feet: .12,D
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ ,-,ODD k 60
2. If Commercial project,what is the proposed use:
3. Are there any structures not shown on the plot plan? YES 0 Explain:
4. Are there any easements on the property? YESOD
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: K/p e'��yi V-6� I^U,��13 6 8C "t �%�
SIGNATURE: ,rznA .17/ DATE: 66A-6 014a
Accessory Structure Application Revised February 2019