application - ' Office Use Only
r
ACCESSORY STRUCTURE Permit#: 1` Vj5 o 2- 43
PERMIT APPLICATION Permit Fee:$ 'a-5
Town of Quccnaburi•
742 Bay Road,Queensbury,NY 12804 Invoice#:
P:518-761-8256 www.queensbury.net
Project Location: `�e�,;"7L�j P
Tax Map ID#: q0. 7—( - ( s Sut vis onName: ��T-'� ��G_
/Vtarkts n.isnie,
CONTACT INFORMATION:
• Applicant:
Name(s): /.rc%t.s/ 2
Mailing Address, C/S/Z: � //L 4,e /0 Cc7«ergo s 644.-, "Wr /04011
Cell Phone: ( .92 ) 79( 77T7 Land Line: ( )
Email: ea? a /7 Addio.w%/eo.�•
• Primaryr Owner(s):
Name(s): � �w
Mailing Address, C/S/Z: 6 ' ,-r 4tQe Pi'
Cell Phone: (S/s' ) `796 -a7 77 Land Line: ( )
Email: �►'� /`77( A. A,// /—+
• .Contractor(s):
Business Name: -
Contact Name(s): , 'o%.✓ G: a, 40
Mailing Address, C/S/Z: 4/4 P Qr,.•i,a��•� �i� /0199if
Cell Phone: (72 ) 7 )0-pr Land Line: (
Email: ,�p re./7c 4. +«%`cep m-+
• Architect(s)/Engineer(s):
Business Name:
Contact Name(s): Ifs .'i n .j i LU1�1 it
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: 1 ( TrtR� n¢a Ong ui
Email: BUILDING&CODES
Contact Person for Building& Code Compliance: et/c.o.— Gyi• ✓
Cell Phone: ( 4'.* ) 7,90"—?? 7 7 Land Line: ( )
Email: 6.7,c /
•
Town of Queensbury Building&Code Enforcement Accessory Structure Application Revised April 2017
t y
PR( ECT 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: a56
2nd floor:
Total square feet: (754
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 (I)
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: /jH P;,i `Qr-�, )/e ✓
SIGNATURE: DATE: s�2 (P
Town of Queensbury Building&Code Enforcement Accessory Structure Application Revised April 2017