AST-0433-2020 fir`: : Office Use Only
1 4., ~ ACCESSORY STRUCTURE ^"u,
�� Permit#: S‘ 4�3 0 " 202- .1
� PERMIT APPLICATION
Town ofQuecnsbury
Permit Fee:$
742 Bay Road,Queensbury,NY 12804
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P:518-761-8256 www.queensbury.net I Invoice#: ""c
Project Location: /Q . Oc,U e K tit
Tax.Map ID#• _2-2-6 f$ --1 XSubdivision Name: // e-tA.t/ f j-
CONTACT INFORMATION:
• Applicant
Name(s): M e G,,, W
Mailing Address, C/S/Z: S— (t,(. �„ ,,„ ,.s1- 'e,t( .ss-L d,tQ, .i✓ { 12.'2-%
Cell Phone: ( r r I ) -tiro - -"ril Land Line: ( )
Email: M,N r-). L.s;IQa s✓ Q /,,.. 1-0,, r t . r.s M
• Primary Owner(s :
Name(s): hie 51- . Po'- 4- L-L L
Mailing Address, C/S/Z:"_ 17/(0 S`e7 C.�l¢, Stal-R `I) v I ti /_l� c , AA r
Cell Phone: (Z..'s ) 9Y A -- S4 y .q- Land Line: ( ) ' a 7 Y /07
Email:
Check if all work will be performed by homeowner only : r-'
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): ( \ or-,-c-- (c, S
Contractor Trade: rn..,-,' o l
Mailing Address, C/S/Z: 5-1 cA4...)P,.,�... —a- `:R, 1A -L -s�q N`i / ?-^-
Cell Phone: ( Sl'I ) zi- -- 1 8 'd->s Land Line: ( )
Email: /4, ,-,. „ l.„n Q h __,„„,-•J .-r�uH
**List all additional contractors on the back of this form
ec
• Architect(s)/Engineer(s): D f7 0
Business Name: JUL I
Contact Name(s): Z 8 2ft?0 !
Mailing Address, C/S/Z: TO Vi Vc1 O� /
Cell Phone: ( ) Land Line: ( U(LDI oEENS-B ,,
Email: tS
Contact Person for Building""&'Lode Compliance:
Cell:Phone: ( ) -%'., Land Line: ( )
Email: , ,�`"�''a!" . . ' . ,
'Accessory Structure Application - Revised February 2019
`PT. k
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), _3-Season Porch
Other(description: r_ l .)
SQUARE FOOTAGE OF STRUCTURE:
1st floor:
2nd floor:
Total square feet:
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$ /el/ f1
2. If Commercial project,what is the proposed use:
3. Are there any structures not shown on the plot plan? YES NO xplain:
4: Are there any easements on the property? 40, 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.
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: 1/41G+�
SIGNATURE: DATE: /5"�Z°
Accessory Structure Application Revised February 2019
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