application Office Use Only
ACCESSORY STRUCTURE
Permit#: .� 2.Z--' �2-0
4a PERMIT APPLICATION
Town of Queensbury 1 2.,�
742 Bay Road,Queensbury,NY 12804 Permit Fee:$
P:518-761-8256 www.queensburv.net Invoice#: 2,6
Project Location: 114 'R'verlr'li20 tuti �IUf,FiVt , NY
Tax Map ID#: 5r34o 306. 14 -l -i( Subdivision Name: et G{ow
CONTACT INFORMATION:
• Applicant:
Name(s): VvriA ( i p, Vt elfin eti
Mailing Address, C/S/Z: Rik rowazook, 0.4a,vcstwry, NH I2004
Cell Phone: (CiU ) 4,91- 3325- Land Line: ( ) �1pb
Email: dbcol opvnait. cewi
• Primary Owner(s): IlUL
Name(s): C'vt1.t4vi 2 7 202
-0:11
Mailing Address, C/S/Z: etc cthivri
Cell Phone: ( ) Land Line: ( TOVI)N 0 orr ►r t
Email: _BUILDING& CODES
❑ Check if all work will be performed by homeowner only
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): v►-1►�mn� kv Li0
Contractor Trade: Co n.s tc,(-r1rbi
Mailing Address, C/S/Z: 6"1 9M -Cir4 1S, KINI 12801
Cell Phone: ( 44) )1 tH - 2-I 51 Land Line: ( ) r41 Pc
Email: 4 v4Itiovi et&t,r i►i o 6 erna cowl
**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: 1 ��cant"
Cell Phone: ( ) Land Line: ( )
Email:
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:
SQUARE FOOTAGE OF STRUCTURE:
1st floor: 2.00 5I11-
2nd floor: ro'
Total square feet: 200 64.t-
ADDITIONAL PROJECT INFORMATION: U
1. Estimated Cost of Construction:$ 16;I t5OID
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.
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: - a. WR I T Nituv I
SIGNATURE: 4r r • 'C�0�� DATE: diAJA1 241 0