application ' 1. t, Office Use Only
i ACCESSORY.STRUCTURE Permit#: PT -. ®6\- I. 2°2 P
,.` _ PERMIT APPLICATION: Permit Fee: $
Town of Qaeensbury
742 Bay Road,Queensbury;NY 12804
Invoice it: �8 cJ
P:518-761-8256 www.oueensburv.net
Project Location: .% `rI Q,57ice_ pr. QiQ Nry
Tax Map ID#: J . ID.- I - 31 Subdivision Name: �5� ��i
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CONTACT INFORMATION:
• Applicant:
Name(s):: 140.* a.,. . n,1.5C7 c�.,1co
Mailing Address, 1)r_ Q o-+✓v4, tJY !2JV
Cell Phone:_( 3is ) rote-7y:os Land Line: _( )
Email: nAa--+- c.r:��10-.) (Z1 CD w.c.l , CO%,1
• Primary Owner(s):
Name(s):
Mailing.Address,C/S/Z: �.1"Le
Cell Phone:_( .:) Land Line: _( )
Email:
r0 Check if all work will;be performed by homeowner only
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contact Name(s): �.�r..;.. 1.,, L�. s . l . LLC: ( ictà .\.�) F
Contractor Trade:
Mailing Address,C/S/Z:. CHI Me,55ik Pr. 0 u ./ L- iJ1.-12M-1
Cell Phone:_( •SIB ) 3U `35-7S Land Line: _( )7
Email: D E C E, Q se E '
**List all additional contractors on the back of this form r
AUG: 18 2020
• Architect(s)/Eneineer(s): - ---
Business Name: TOWN OF OUEENSEL'RY
BUILD11iNG&CODES
Contact Name(s): ; -----
Mailing Address,C/S/Z:
Cell Phone:_( ) Land Line: _( )
Email:
Contact Person for Building&Code Compliance: MA•r' �A� LA j
Cell Phone:_( . 31 S ). /0 0 7`03 Land line: (: ) .
Email: ►'v a n cam\ai .29 @_1.~ia,l • cc).;r.
Accessory Structure Application Revised February 2019
PROJECT INFORMATION:
TYPE: 0 Commercial X Residential
WORK CLASS:
O Deck,Open Porch 0 Solar Panels.(w/o rafter upgrades) 0 Carport 0 Cell Tower
Shed 0 Pavilion, Pole,Barn,Canopy 0 Dock 0 Gazebo
❑ Detached Garage 0 Boathouse(with or w/o sundeck) .❑ 3-Season Porch
O Other(description: )
SQUARE FOOTAGE OF STRUCTURE: ..
1st floor: 12-X 20 2PiO 51/ '•
2"d floor:
Total square feet: 2'10
.
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction $ -11 C0a
2. If Commercial project,what is the proposed use: 1431
3. Are there any structures not shown on the plot plan? YES NO Explain:
4. Are there any easements on the property? . YES 0 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: i-C
SIGNATURE: DATE: 131 Zb2O
Accessory Structure Application Revised February 2019