application i r • 1
Office Use Only
1°11111111;, . . ACCESSORY STRUCTURE Permit#: RSA - z.)6'1-- - Zp ZC)
PERMIT APPLICATION Permit Fee: $ 1.°2_ •5G
742 Bay Road,Queensbury, NY 12804 Invoice#: 9
P:518-761-8256 www.queensbury.net
Project Location: O C 1Ui- VA/s0C, POND
Tax Map ID #: 2CIO. 1 — 1 . ` Subdivision Name: Ni.
CONTACT INFORMATION:
• Applicant: ``
Name(s): ?*t.A IA. ' NPJs
Mailing Address, C/S/Z: Zett? CA-kc:1-- cWU1 rAt 01O
Cell Phone: (_SV22 ) 4 = 1'2 1 Land Line: ( 6 is ) 1'12--21 U7
Email: p1(, qL bkosyr law • C,4r r
• Primary Owner(s):
Name(s): AMVI -AS kcPt tC 1"-. - 7. v. .
Mailing Address, C/S/Z: ,
Cell Phone: I ) Land Line: 4r)� %`
Email: L I. , J -',..
i
TOWN OF QUEE14;i URY i
• Contractor(s): BUILDING&CODES
Business Name: f. IZ• UJ1'CZ 16Ul1LA 6
Contact Name(s): 'Z w r2.
Mailing Address, C/S/Z: 3 115 t Ate Si ufQI44SSIIet ? ( rass
Cell Phone: t'. ) .4 ' — ;• 40 Land Line: )
Email: c_- •._ri in ' • (Se on5( -61VS548 a ¶jahoo. cOr1
• Architect(s)/Engineer(s):
Business Name: 14(UI01*SK-1 -1-INA., -1 I L'f.A
Contact Name(s): f P . -4iAlx.-
MailingAddress, C/S/Z: V DI Ne &A.Aia.ls 4AtA 4i( SO(
Cell Phone: ( 'E* J) 20o. 2 Land Line: ( 568 ) - 2.e
Email: Øct \ c..gq • re. Cowl
Contact Person for Building & Code Compliance: i* P. 't-thUL
Cell Phone: ( 7i�$ Land Line: ( '510 ) 141 -OZC,
Email: a Ylot I 11 GGl�• CC. �m
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Town of Queensbury Building&Code Enforcement Accessory Structure Application Revised April 2017
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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
J Detached Garage _Boathouse (with or w/o sundeck) _3-Season Porch
Other(description: COV eG0wt-'
SQUARE FOOTAGE OF STRUCTURE: � �,�,�,,II
1st floor: SU1 SF '�' '1// O
W Ip(
2nd floor: ((��
Total square feet: `1l VJ
ADDITIONAL PROJECT INFORMATION:/�
1. Estimated Cost of Construction:$ 0 0d0
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
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 aboye:
PRINT NAME: r A1J r• • - k'G4-+'1141 K r e-14`-r
SIGNATURE: Skin 41 �' / DATE: / -Ala 2;049
Town of Queensbury Building&Code Enforcement Accessory Structure Application Revised April 2017