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application Office Use Only ACCESSORY STRUCTURE _ � 2O� - / Permit#: � PERMIT APPLICATION Town of Queensbury Permit Fee:$ 742 Bay Road,Queensbury,NY 12804 aa P:518-761-8256 www.queensbury.net Invoice#: 2U 1-11 Project Location: 3 LYx. L bw(-y Tax Map ID#: 3 h 2. Subdivision Name: CONTACT INFORMATION: • Applicant: Name(s): Z't-)1n n M- )J OJV ea-f-'A i c , b� Mailing Address, C/S/Z: 5 11/t r,e, Cs) u rb _) Cell Phone: ( 6 I$ ) °j 5-S--6 l `5 Land Line: ( 5( S--) `Z R3- ? Email: koui c_o et,) e- In , -ma_`+ e-o rn • Primary Owner(s): Name(s): kY\ ci- • Mailing Address, C/S/Z: 3 5 5 4-9)kci,iz.i i✓ Lam, k`e.`e,PL_5 l (A r'y Cell Phone: ( S ( 5V") ?S 5- , 1 7,5 Land Line: (b`Z g ) 7 q3_7 41 8"" Email: Kck . Co r ckA ate_ n^n ❑ Check if all work will be performed by homeowner only, • Contractor(s):Workers' Comp documentation ust De mitte w h this app ication Contractor Name(s): 6-c7,e, rv\Ja --d Oat" t11e- pwlo &:ttrste, Contractor Trade: 5 fvo_S u_t Ole �{-�- - 9- i SrA roz- �5 ) Mailing Address, C/S/Z: 5 p konLh 1kJ1- iy► ( � (a58"3 I Cell Phone: (51 ) x3Ol Land Line: Email: W cv v o G-c '`en Nv\v Co **List all additional contractors on the back of this form c014 0,,,i` z c col w o rk.t is ,', CAlite OforAt,, gi'tiora o» Alt- • Architect(s)/Engineer(s): Business Name: ;11 & 'e)' 10Wn 1'411 518 '793-2ssS x 301 Contact Name(s): Mailing Address, C/S/Z: Cell Phone:_ ( ) Land Line: Email: AUG 0 7 2020 3 I Contact Person for Building&Code Compliance: AvVIC40--- M TOWN OF OUEENS URY Cell Phone: ( ) Land Line: ( Email: Accessory Structure Application Revised February 2019 .-' i PROJECT INFORMATION: TYPE: Commercial 7c Residential WORK CLASS: Deck,Open Porch _Solar Panels(w/o rafter upgrades) _Carport _Cell Tower —Shed _Pavilion,Pole Barn,Canopy _Dock Gazebo i`t.1Ci b Detached Garage _Boathouse(with or w/o sundeck) _3-Season Porch 1 . JGe. 'sib) ,t.GM t Other(description: ) 2.. )1443, pic.p J SQUARE FOOTAGE OF STRUCTURE: 3. P;ag4 w Of' Cabin 1st floor: 2nd floor: Total square feet: I q a- ADDITIONAL PROJECT INFORMATION: 1. Estimated Cost of Construction:$ t „.3 0 t©iQ •.•. 2. If Commercial project,what is the proposed use: • 3. Are there any structures not shown on the plot plan? YES 0 Explain: 4. Are there any easements on the property? YES 66) 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: Al {tLi i_n I`e --Co u'.` J r SIGNATURE: `'l J/71 DATI 0 co Accessory Structure Application Revised February 2019