application Office Use Only
ACCESSORY STRUCTURE
Permit#: Pt—- D(-(OS- 2-020
4 PERMIT APPLICP N.
Town of Quccnsbury U rr� F�: $ l 2 Cr 00
742 Bay Road,Queensbury,NY 12804 u I r�
JUL 1 U Z P:518-761-8256 www.queensburv.net J ypice 4: 2---�7_(
�u�LUU -
Project Location: 2-. 87 S�� r 1--
TOWN OF QUEENSBURY
BUILDING&CODES
Tax Map ID #: z4 v 15 - ( — Zz ' Subdivision Name:
CONTACT INFORMATION:
• Applicant:
Name(s):_ _JAkiE 1-4 C-L i)—k J of
Mailing Address, C/S/Z: ZS`c —7 S�ter-_ er 4--
Cell Phone: (6-1 & ) z2 Z. I Land Line: ( )
Email:
• Primary Owner(s):
Name(s):
Mailing Address, C/S/Z:
'sCell Phone: ( ) Land Line: (
Email:
❑ 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): is1 's rpRp (-r>i c1-- 1-/i4toile2
Contractor Trade: H Aso J\rv_-% Ccurvc__,
Mailing Address, C/S/Z: Ls,�r-L IL1._.0 PS 4\./. u ( ZE-c)
Cell Phone: ( 51 fr ) 33 a- Lo 13 i Land Line: (SI 8- ) ^l qia- Coco c4
Email:
**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: AID ? l C-/Ar►•t
Cell Phone: ( ) Land Line: (
Email:
Accessory Structure Application Revised January 2020
PROJECT INFORMATION:
TYPE: Commercial ` Residential
WORK CLASS:
D-el( O,l P.M lorPh _Solar Panels(w/o rafter upgrades) _Carport _Cell Tower
Shed _Pavilion, Pole Barn, Canopy _Dock _Gazebo
Detached Garage _Boathouse (with or w/o sundeck) _3-Season Porch
_Other(description:
SQUARE FOOTAGE OF STRUCTURE:
1st floor:
•
2nd floor:
Total square feet: L C.OSr
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $
2. If Commercial project,what is the proposed use:
3. Are there any structures not shown on the plot plan? YES NO Explain:
4. Are there any easements on the property? YES NO
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.
4 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: �INA_S
SIGNATURE: - 1 (- DAT - I
Accessory Structure Application Revised January 2020