application Office Use Only
ACCESSORY STRUCTURE
PERMIT APPLICATION Permit#: - I : o
2 B n((Zucad,Qy , E C E ry p n $ I�� oO
U V [ miit Fee: ,
742 Bay Road,Queensbury,NY 12804 D p P:518-761-8256 www.queensbury.net I Bice #: II�P�1'/
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JUN 11 2019
Project Location: 1 Orc h&r ) —
TOWN OF QUEENSBURY
BUILDING
Tax Map ID #: subdivision Name:
CONTACT INFORMATION: ] � Q c, J eOIOw• G6��
DUI 4,
• Applicant:
Name(s): (-A\v)'41/ Le,1'r A
Mailing Address, C/S/Z: / (�c-- a rat Or
Cell Phone: (631 ) ,AS8'^F-V43 Land Line: ( )
Email: devaiCm Leov7 C` l.),-'Vi , r.A5►"'7
• Primary Owner(s):
Name(s):
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: (
Email:
►� Check if all work will be performed by homeowner only
• Contractor(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:
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: (
Email:
Contact Person for Building & Code Compliance: 5v C-
Cell Phone: ( ) Land Line: (
Email:
Accessory Structure Application Revised February 2019
/
PROJECT INFORMATION:
TYPE: Commercial Residential
WORKOR 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: OIJ
Total square feet: G
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ 7( DO@
2. If Commercial project,what is the proposed use:
3. Are there any structures not shown on the plot plan? YES 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:
SIGNATURE: � DATE: 211
Accessory Structure Application Revised February 2019