application Matki Coe\ j cV ( Q)' Office Use Only
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Permit#:
PERMIT APPLICATION
Town ofQueensbury Permit Fee:$
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net Invoice#: 51 1/40-Z
Project Location: 2-1 4eAn Vit,cSC'
Tax Map ID #: D31- 8- I - Subdivision Name: �. l
NOV 17 2020
CONTACT INFORMATION: 1
TOWN OF OUEENOEURY
BUlLUNG CODES
• Applicant: .R_._
Name(s): 1 t�
ailing- acre-_s,-C/S/Z:=�J1 .4-�
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Cell Phone: _(S 11g ) (3a- 04,5O Land Line: _(
Email: ��,I �ac�\-ems I wt.a.i I i Cat
• Primary Owner(s):
Name(s): (t eavt -Troy �l
Mailing Address;'C/S/Z:2.1 � �n
+ nck Shre-er , Que,-etn `'r9 r ' 14
Cell Phone:_(51' ) OM C. Land Line: _(
Email: li--)61I :Sean e.u) (@ 3r vvu ,C_1?fl
g Check ifall work will be performed by homeowner only
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contact 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:
Contact Name(s):
Mailing Address, C/S/Z: •
Cell Phone: _( ) Land Line: '_(
Email:
Contact Person for Building & Code Compliance: \C r
Cell Phone: _( ) Land Line: _(
Email:
Accessory Structure Application Revised February 2019
PROJECT INFORMATION:
TYPE: ❑ Commercial Zesidential
WORK CLASS:
•
❑ Deck, Open Porch ❑ Solar Panels(w/o rafter upgrades) ❑ Carport ❑ Cell Tower
❑ Shed ❑ Pavilion, Pole Barn, Canopy ❑ Dock ❑ Gazebo
El Detached Garage El Boathouse (with or w/o sundeck) El 3-Season Porch
Q Other(description: .)OVl tI Y(JOY)
SQUARE FOOTAGE OF STRUCTURE:
- _ - -
2"d floor:
Total square feet: 1 1 J
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ , e
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: l lu L'A,(j) S
J 5
SIGNATURE fek ,L ,Biy—) DATE: " I 6�\aoo
Accessory Structure Application Revised February 2019