AST-0516-2020 Office Use Only
ACCESSORY STRUCTURE
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• �_ PERMIT APPLICATION Permit#: /
Town of Queensbury
Permit Fee:$
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net Invoice#:
Project Location:7 flu f r&y Ave- C2,..L ce n S io u
Tax Map ID#: 30? e /L( — — coy- r Subdivision Name:
CONTACT INFORMATION:
• Applicant: _
Name(s): Ale; Dkirt-Y,e,.
Mailing Address, C/S/Z: 7 /1 t,cc-r-&.y Ave— Q I;ke-ens bury , �✓ `� /��D�
Cell Phone: (S/F( ) a( FS.2 Land Line: ( .4/7/f )
Email: fl e-i ( a(A-1C-e5ne )/6kooC-o1
• Primary Owner(s):
Name(s): . - rpac-c J)R Fi'esn —
Mailing Address, C/S/Z: 7 PI E-krr<y ve- ikee-r95bur i /v7 / For
Cell Phone: ( .5! �( ) (� / 7 �5 Land Line: (/✓/i9 ) y
Email: i) /I d uj're-Sne C) yahoo tc-oi
1 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: ( )
Email:
**List 7
all additional contractors on the back of this �
• Architect(s)/Engineer(s): . I r AUG 312020
Business Name:
t Oi tA`: E.•��,}��E'+i`�.,�re..�l'S
Contact Name(s): ! RIM ntM �. r�r�pe�
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: ( )
Email:
Contact Person for Building & Code Compliance: 1k.ceeink--
Cell Phone: ( ) Land Line: ( )
Email:
Accessory Structure Application Revised February 2019
{ PROJECT INFORMATION:
-s
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: 2 FS 5t
2"d floor:
Total square feet:
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ 'YOOO _.5h00
2. If Commercial project,what is the proposed use: /V/A
3. Are there any structures not shown on the plot plan? YES NO Explain:
4. Are there any easements on the property? YES 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 I Dp�re-sh e
SIGNATURE: 724DATE: 7//40.2 0
Accessory Structure Application Revised February 2019
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LEGEND *yooi'yP is�°9�
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Anthony Mercadonte •
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Oueensbury. New York f2804 -_
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