application Office Use Only
ACCESSORY STRUCTURE
� Permit#: PcS1 — ®51� ZC)ZO
PERMIT APPLICATION
Town ofQucensbury Permit Fee:$ 1 L!)
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbuMaim
rv.net Invoice#: Z�
Project Location: /� / Az /64
Tax Map.ID #: 5-2_3 Yo0 2R I , Subdivision Name:
CONTACT INFORMATION:
• Anglican : f/ /y.
Name(s): Vita/di ah0( i i'i &c
Mailing Address, C/S/Z: S Pr idays 6C' ftc A /280( _
Cell Phone: (376 ) �_�—® Land Line: (fie ) 79a—/ e9?
Email: 0)cy P►']ojes' (yOhl
• Prima Owner s :
Name(s): : .t 'A 1- O & /2N to c
Mailing Address, C/S/Z: •.'2- �' ei^li N A , ./IS CS', /2_80
Cell Phone: .( 7 ) Z — S Land Line: ( 79 ) 7'72_— et7.3
Email: ,01C)Y)111 A?C" aA/-C /n
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Check if all work will be performed by homeowner only,
• 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: (_.. �� I
Email: c r, R. 11
**List all additional contractors on the back
• Architect(s)/Engineer(s): Sip 03 2
020
Business Name: - t TOVt«'OF QUEENSBUR'r
Contact Name(s): BUILDlNycQUCs------`
Mailing Address, C/S/Z:
Cell Phone: J ) Land Line:
Email:
Contact Person for Building& Code Compliance: ot 1 k t
Cell Phone: ( ) Land Line: ( )
Email:
Accessory Structure Application Revised February 2019
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
Y Other(description:
SQUARE FOOTAGE OF STRUCTURE:
1st floor:
2'floor:
Total square feet: 3 3�
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$ 2., 52O t
2. If Commercial project,what is the proposed use:
3. Are there any structures not shown on the plot plan? YES e Explain:
4. Are there:any easements on the property? ' 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: L -
SIGNATURE: DATE: 0- Z0Zb
Accessory Structure Application Revised February 2019