application fit ACCESSORY STRUCTURE Office Use OnI_y
PERMIT APPLICATION Permit#: AST- b -2 7D
Town of Queensbury
Permit Fee: $
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net Invoice#: 2�
Project Location:A'7ALja.h/ UIe/ Pt' •
Tax Map ID #:_.5-:,3*O /— 62 Subdivision Name: rk`/im
CONTACT INFORMATION:
• Applican :
Name(s): C 6iJ I2 ci �D(,L�h
Mailing Address, C/S/Z: d( ' cDf gr • L Wil.SLyY A) /dROY
Cell Phone: /k ) - O Land Line: (.S 7 S ) / 3 S
Email: `1 b pL OtO , Cd hi •
JC`�
• Primary Owner(st
Name(s): ffie 2' alb Ol f
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: (
Email:
❑ Check if all work will be performed by homeowner only
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): A6tc.. �5 y. 6ftte_bc6
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: (
Email:
**List all additional contractors on the back of this form
• Architect(s)/Engineer(s):
Business Name: 1 1.1
Contact Name(s): (' JUL
7,
Mailing Address, C/S/Z: `
;
Cell Phone: ( ) Land Lie: s �n�; E= ��; _ ' z:'
Email:
Contact Person for Building & Code Compliance: Artkayst--
Cell Phone: ( ) Land Line: (
Email:
Accessory Structure Application Revised February 2019
PROJECT INFORMATION:
a Z
TYPE: Commercial Residential
WORK CLASS:
Deck, Open Porch _Solar Panels (w/o rafter upgrades) _Carport _Cell Tower
hed pr)e_hu'it _Pavilion, Pole Barn, Canopy _Dock _Gazebo
del ive�^eGf
Detached Garage _Boathouse (with or w/o sundeck) _3-Season Porch
Other(description: ) C%
C/6
SQUARE FOOTAGyeiSTUUKa 0 kg
1st floor:
2"d floor: ,
Total square feet:
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ ''Qt' /
2. If Commercial project, what is the proposed use: 44
3. Are there any structures not shown on the plot plan? YES dr) Explain:
4. Are there any easements on the property? YES N•
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: i�9.5 Jf Mon r-\ my L. h roron
SIGNATURE. �a / %...-
9411,4d X k24014Th.— DATE: 6'/7 ",
Accessory Structure Application Revised February 2019