application �=- Office Use Only
r°`'I •
ACCESSORY STRUCTURE /1-.
f Permit#: �S� - DQ • 2�
--- �3 PERMIT APPLICATION Town ofQeeizsbury Permit Fee:$ 9 1 2-
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742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensburv.net Invoice#: 2 -Z
Project Location: 1 Ceden 11 f 4/ Of nit'
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a
Tax Map ID#: .t-Z34 3c,1_J.-//Subdivision Name:
CONTACT INFORMATION:
• Applicant:
Name(s): vfbv.v ncri4i
Mailing Address, C/S/Z: 4 (e,cl- r,ict ( 1�rivF 0 Lke ,s ciiy IVY I O
Cell Phone:_( Sig ) `7uif-4i 73 Land Line: ( S78 ) ` 90-0Z-7
Email: tiy cC
�' t r1nE?,lrfr lO c� mall corn - E e- LEAV
• Primary Owner(s): JUL 1 3 2020
Names)/ )( eP c r`
C9/tt'i/
Mailing Address, C/S/Z: 4- C`r yilersrl(Ol a &1 7 IUiY /' [aLipE, E�rG ��
Cell Phone:_(S 14 ) j j/-4123 Land Line: _(t— ) 77 �C!Z Y f =—,
Email: c:yiriAro-ifr`U e j pn /1: Carn
❑ Check if all work will be performed by homeowner only
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contact Name(s): Mc 4 r/ ,�a/
Contractor Trade: (, a ,nnyl
Mailing Address, C/S/Z: Ma . .•-riL Al 4.1, ,,,-,L Li 3'V•Ps
Cell Phone:_( cri ) 36)-a j1 JL) Land Line: _( 0 )
Email: fnil 4 ✓g >ldius' LL
**List all additional contractors on the back of this form
• Architect(s)/Engineer(s):
Business Name:
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line: _.( )
Email:
Contact Person for Building & Code Compliance: . 'y 1 �h/10
..(7(
Cell Phone: ( Sib ) ?91 4123 Land Line: . (S/8/ ) 72 D2c'( ..
Email: exyarThell.t
Accessory Structure Application , — Revised February•2019
PROJECT INFORMATION:
TYPE: ❑ Commercial f,5; Residential
WORK CLASS:
Deck,Open Porch ❑ Solar Panels(w/o rafter upgrades) ❑ Carport ❑ Cell Tower
1Ce f ac='merit of Fxis'4ir5 Deck
❑ Shed ❑ Pavilion, Pole Barn, Canopy ❑ Dock ❑ Gazebo
❑ Detached Garage 0 Boathouse(with or w/o sundeck) ❑ 3-Season Porch
❑ Other(description:
SQUARE FOOTAGE OF STRUCTURE: -
1st floor:
2nd floor:
Total square feet: 2 0
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$ /0, 00
2. If Commercial project,what is the proposed use:
3. Are there any structures not shown on the plot plan? 631 NO Explain: S 66.01
4. Are there any easements on the property? 0 YES NO
DECLARATION:
]. I acknowledge that no construction shall be commenced prior to issuance of a valid permit and will be
completed within a 12 month period. c ter' '„ , a-�--->
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.
1' cknowledge that prior to occupying the facilities proposed I, or my agents, will obtain a certificate of
occupancy.
` �I
. I asb 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: 79, Amv' P nip i
SIGNATURE: G U vr�f DATE: 7//.?/?O
Accessory Structure Application Revised February 2019