application Office Use Only
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F� �' ACCESSORY STRUCTURE
Permit#: AST- 050 l - 7-fl 2P
. PERMIT APPLICATION Permit Fee:$ 11-5
Town of Quccnsbury
742 Bay Road,Queensbury,NY 12804 Invoice If: 2103
P:518-761-8256wuwv.queensburv.net
Project Location: Ll4 Mali 0 c y Cam,
TaxMaplD#: Oc1• c 2 '2-so Subdivision Name:
CONTACT INFORMATION:
• Applicant:
Name(s):jcu of)
Mailing Address, C/S/Z: mCA. to ntof2._49 t 1_20 if
Cell Phone:_(s CS )794,76( 7 Land Line:_(__)
Email:
• Primary Owner(s):,.,
Name(s) 1)ai )fl iA1�-
Mailing Address, C/S/Z: M 0 cj eu.2,, �,PQs►.(l
Cell Phone _(5(4 3 )746?'6e;t-7.- //Lyyapn�d-yLine: _( M )
G. C 1 Email: P M .W)Krae O I►ti+c� 1 oS\ ('o 1
12(Check if all work will be performed by homeowner only
• Contractor(s):Workers' Comp documentation must be submitted with this application
Contact Name(s): our,V,¢_At
Contractor Trade: r9 ruxt
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line: _( )
Email: E c n
**List all additional contractors on the back of this form u wy
• Architect(s)/Engineer(s): AUG 2 4 020
Business Name: TOWN OF QU��RISE
Contact Name(s): eU1LD1v0 C�poa �r
Mailing Address, CAA:
Cell Phone:_( ) Land Line: _( )
Email:
Contact Person for Building&Code Compliance: AWyc60(4-
Cell Phone:_( ) Land Line: _( )
Email:
Accessory Structure Application Revised February 2019
l~�
PROJECT INFORMATION:
TYPE: ❑ Commercial Il Residential
WORK CLASS:
❑Deck,Open Porch ❑Solar Panels(w/o rafter upgrades) ❑Carport ❑Cell Tower
DShed ❑Pavilion,Pole Barn,Canopy ❑Dock ❑Gazebo
XIJ Detached Garage ❑Boathouse(with or w/o sundeck) 03-Season Porch
❑Other(description: )
SQUARE FOOTAGE OF STRUCTURE:
1st floor:
2"d floor:
Total square feet: 51
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$ i31600_e
2. If Commercial project,what is the proposed use:
3. Are there any structures not shown on the plot plan? YES �f�NO Explain:
•
4. Are there any easements on the property? ❑ YES L NO
DECLARATION:
1. lacknowledge thatnoconstructionshallbecommencedpriortoissuanceofavalidpermitandwillbecompleted
withinal2monthperiod.
2. Ifthework isnot completedby the lyear expiration datethepermit may be renewed,subjectto feesand
departmentapproval.
3. Ice rtifythattheapplication,plansandsupportingmaterialsa reatruea ndcom pletestatementand/or
descriptionoftheworkproposed,thatallworkwillbeperformedinaccordancewiththeNYSBuildingCodes,localbuildinglaw
sandordinances,andinconforma ncewithlocaizoningregulations.
4. Iacknowledgethatpriortooccupyingthefacilitiesproposed I,ormyagents,will obtainacertificateofoccupancy.
5. lalsou nde rstandthati/wea rerequiredtoprovidea nas-
builtsurveybyalicensedlandsurveyorofalinewlyconstructedfacilitiespriortoissua nceofacertificateofoccu pa ncy.
I have read and agree to the above:
PRINT NAME>IIAern. S`fir
SIGNATUREI -t,LW) _s�U CY DATE: Is^ice
Accessory Structure Application Revised February 2019