application l a
of Office Use Only
j- ACCESSORY STRUCTURE
\-'' PERMIT APPLICATION Permit#: S (, d �3.5 -2A��
Town of Quecnsbury I 2—57 o 0
742 Bay Road,Queensbury,NY 12804
Permit Fee:$
P:518-761-8256 www.queensbury.net Invoice#: I 6(
Project Location: y 1,63J➢1 pet_t-f- l l et.
Tax Map ID#: cSZ3 yoD 3 02,7-/- 2S— Subdivision Name:
CONTACT INFORMATION:
• Applicant:
Name(s): -Te,in.. /LW b
Mailing Address, C/S/Z: // (,_i -&' �� uc AJs Q j� AJV
Cell Phone: ( S-7 P ) 2-3 Z-O t 0 Land Line: ( )
Email: g ICbn_J=h� j wffrh. do /`7
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• Primary Owner(sA):
Name(s): - tlb' 19 / tutz2 &-
Mailing Address, C/S/Z: 2.S- O/e,.3 e-„) Sr. CA ogerAks Q ur,,.ty /( J ZJO y
Cell Phone: ( ) Land Line: ( / ) /
Email: .
Check if all work will be performed by homeowner only
•_ ontractor(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 all additional contractors on the back of this form
• Architect(s)/Engineer(s):
Business Name: G%14SY-4 . 1/.. Pe-Ca i LIV-�
Contact Name(s): . =4-N .14 444Sld
Mailing Address, C/S/Z: t ek.. S g 12o1
Cell Phone: ( ) Land Line: (. 516 ) —02(08
_Email: ` f n ttkV cete.r'r. coral
Contact Person for Building & Code Compliance: ,AA P•4-1p14
Cell Phone: ( ) Land Line: ( 1Q ) 141 -02/0e)
Email: efbetlI CO3 czte.re. Cowl
Accessory Structure Application Revised February 20194
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:
2"d floor:
i Q
Total square feet: x.
...
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$ Z MD
2. If Commercial project,what is the proposed use:
3. Are there any structures not shown on the plot plan? YES N)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: Ana J7 &x
n--
SIGNATURE: DATE: ZLe
4 9
Accessory Structure Application Revised February 2019