AST-0619-2020 J- Office Use Only
1 ACCESSORY STRUCTURE
\4, Permit#:AST"-Flo tv 2 O 2-0
PERMIT APPLICATION
Town of Queensbury Permit Fee:$ �`�
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensburv.net Invoice#: ✓0/1'tio
Project Location: 5ct 'N`c.Ecarwrc, Lr1.Map ID#: \• 14V Z " 2 -- Subdivision
CONTACT INFORMATION: OCT 0 7 2020
• Applicant: ,J TOWN OF QUEENSBURY
Name(s): _v 1>J 40(ES— BUILDING&CODES
Mailing Address, C/S/Z: LINZ" Coew\- C1 QL-e-011710tAto,y /Ll' I7�6
Cell Phone: (51B ) 2(06 4310 Land Line: ( ) itk
Email: 41 d AiLNt rkcylk.n e beak C0
• Primary Owner(s):
Name(s): Q_obtQ2s' WAR_ T&c
Mailing Address, C/S/Z: JQ aa1`1, r gL / A/ 12.76V
Cell Phone: ( ilb ) ' c 1 -("AS Land Line: ( ) �.1A
Email: I.Ina.ak 2�eyf167-Gown,
❑ Check if all work will be performed by homeowner only
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): '-- (��12 - ap
Contractor Trade: q A�
Mailing Address, C/S/Z: L4LI C 1r \\ ¢?.d Quc ,\ Ny / oV
Cell Phone: ( j$ ) 7id yS/ Land Line: ( ' r9
Email: / w e - ne�`rgaL Goa
**List aYl additional contractors on the back of this form
• Architect(s)/En ineer(s): L
Business Name: SCA,A u Cv`4-Q VAU-
Contact Name(s): 1,\
Mailing Address, C/S/Z: 13+4 DiAt C\j►IL GUI YLS ilk % 9/ %zod 1
Cell Phone: ( 516 ) 2( o -2.6t8 Land Line: ( 518 ) Ni- - OZ oS
Email: -2pInamPrnc.c a('C• Go'
Contact Person for Building&Code Compliance: /AI
Cell Phone: (1.9) ) 2.000-1- \( Land Line: ( ) N 14
Email: inb1�U) -CIOw�ll\d�V�
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
Other(description: )
SQUARE FOOTAGE OF STRUCTURE:
1st floor:
2nd floor:
Total square feet: 200
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$ 131(Q(Y3
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 tote . 'ove:
PRINT NAME:
SIGNATURE: � . v c_)ea._ DATE: IO\-1 Z0
Accessory Structure Application Revised February 2019