application Office Use Only
4 ACCESSORY STRUCTURE
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Permit#: -
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PERMIT APPLICATION ff
Town of Queensbu ry Permit Fee:$ �Z5
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net Invoice#:
Project Location: olO !4c/e cPr QJt aboy
Tax Map ID #: c - Q \ Subdivision Name:
CONTACT INFORMATION:
• Applicant:
Name(s): $D 5 GoIbre to ( -o.' Ora- /01Yo1 P
Mailing Address, C/S/Z: f L LT,.11 5cT thbesd►.. -fr 115
Cell Phone: ( ) .7,2- e Land.Line: ( )
Email: Serf T617..-a r` o ,cam►�
• Primary Owner(s):
Name(s): tAo(u Th,191.
Mailing Address, C/S/Z: 24 `AA z. dr: CPOr n5 bury' 1/1/:
Cell Phone: (6"1r ) 7ctl Land Line: ( )_
Email:
0 Check if all work will be performed by homeowner only
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): c env ,ca-try rse,d 077cv�/y t kt-c9
Contractor Trade: C.,nercti/
Mailing Address, C/S/Z 2_ o✓1I gT i1icisem, rt/S
Cell Phone: ( f y ) cver Land Line: ( )
Email: su>7 4 t Z (dawlyeti%dc r Com,
**List all additional contractors on the back of this form
•
Architect(s)/Engineer(s): IBusiness Name:
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Contact Name(s): tl , F Q, � o?P
Mailing Address, C/S/Z: ` d 1: 1 I
Cell Phone:_ ( ) Land Line: No' Q i r .1
Email: L
Contact Person for Building& Code Compliance: CpV-ikvaC O✓
Cell Phone: ( ) Land Line: ( )
Email:
Accessory Structure Application Revised February 2019
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PROJECT INFORMATION: /
TYPE: Commercial I Residential
WORK CLASS:
ii)eck,Open Porch —Solar Panels(w/o rafter upgrades) Carport —Cell Tower
Shed —Pavilion, Pole Barn,Canopy —Dock —Gazebo
_Detached Garage —Boathouse(with or w/o sundeck) 3-Season Porch
Other(description:
SQUARE FOOTAGE OF STRUCTURE:
1st floor:
2"d floor:
Total square feet: 1 4d
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:•$ 35—d +. A.1
2. If Commercial project,what is the proposed use:
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: -s c_z,7 OM Luc; d
SIGNATURE: ' x� �( 4--' DATE: ✓ )0
Accessory Structure Application Revised February 2019