application P Office Use Only
• i ACCESSORY STRUCTURE
Permit#: AST'— f9c - 20243
PERMIT APPLICATION
175
Town ofQuccnsbury Permit Fee: $
742 Bay Road,Queensbury,NY 12804 �� i
P:518-761-8256 www.queensburv.net Invoice#: `�
Project Location: 5/, 1 aAo&Ci (:7'
Tax Map ID #: 3!)c7, J o'-Sa-- Subdivision Name:
CONTACT INFORMATION:
• Applicant:
Name(s): VI
Mailing Address, C/S/Z:'��f Ce�irx cr�.ci d72 £7(1 '- c'L CA ey A) /2cft -7
Cell Phone: ( S7 y- ) ' 66 —CP �d2 Land Line: (
Email: hCpf-h s'Aas-Ya- 74//1 air/ p e
• Primary Owner(s):
Name(s): A-S A-6o�-�
Mailing Address, C/S/Z:
Land Line:
Cell Phone: ( ) ( } r )Email: I AUG_I 21 2020 L)
u OF CL, S,..it,
i Check if all work will be performed by property owner`o ly;�p , E. t-.,.-
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: ( )
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: )i cfi
Cell Phone: ( ) Land Line: )
Email:
Accessory Structure Application Revised January 2020
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 ��II Boathouse (with or w/o sundeck)�� _3-Season Porch
Other(description: Ned/ 6 A/r -�y dcz/ /'T- J)U6-4 LV 4&Ov-€
/44 41 ` ‘`dsoh1 S
SQUARE FOOTAGE OFFS STRUCTURE:
1st floor:
2nd floor:
Total square feet: l4ZI
ADDITIONAL PROJECT INFORMATION:
Orp 1. Estimated Cost of Construction:$ 1,800 • /
r
2. If Commercial project, what is the proposed use: A.Vitt
3. Are there any structures not shown on the plot plan? YES NO xplain: AJ0 # /e,-�, la J(
4. Are there any easements on the property? YES NO' r f`G /n.Ck. aok,,C/J\--Lio
cf'o o/U•
DECLARATION: /-J-Ire&cht eve 6-0 70 l Kati,or,
1. I acknowledge that no construction shall be commenced prior to issuance of a valid permit and will be boat_
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: A2/4a 07a
SIGNATURE: ,AtiZaa L�,'( DUC�itc2 DATE: &p?O
Accessory Structure Application Revised January 2020