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application Office Use Only ACCESSORY STRUCTURE PERMIT APPLICATION Permit#: YST - Dbcl 2- -2-0Z O 42 Bay Roa ,Queensbury,NY 12804 Permit Fee:$ P:518-761-8256 www.gueensbury.net Invoice#: Project Location: QIP CW Fi flclS 4DY-, Tax Map lD#: `Z$�j , t�-i!-3Y Z Subdivision Name: !f'J Fields CONTACT INFORMATION: • Applicant: Name(s): 'n'NornLtS ° (,1.� n Mailing Address, C/S/Z: Ate 6.1.E Fidds, 1--A'. &W-16S.6u_r a ID964 Cell Phone:_(vim ie ) Q55 - Lo5 4 0 Land Line: E m a i l: i i (� ,�hc�• Gom - • Primary Owner(s): Name(s): Q C 0_6cV� Mailing Address, C/S/Z: Celi-Phone: Land Line: _( ) Email: ❑ Check if all work will be performed by homeowner only • Contractor(s): Workers' Comp documentation must be submitted with this application Contractor Name(s): &P-o 010 Contractor Trade: U6M6 1MP&VEMl? �' Cc�i�S7nt.�ei?�iUnl-C��✓ �- Mailing Address, C/S/Z: 12,e Cell Phone: _( 51S ) �l`��-�oia� Land Line: Email: 4yy'C,,)r)s4ruc,-hv,Z3 MCI(.I, CO/VV "List all additional contractors on the back of this form • Architect(s)/Engineer(s): — Business Name: Y��`�' - F!f- l f� Contact Name(s): Mailing Address, C/S/Z: ) 11 ra 2020 U Cell Phone: Land Lined U : ) — Email: T6�1 CIF 0_UEH°•i��;E.tic t Contact Person for Building & Code Compliance: %(.n Cell Phone: .Land Line: Email: Accessory Structure Application Revised February 2019 43.1 r - PROJECT 1I \9¢ORMATION: TYPE: Commercial Residential WORK CLASS: I V Deck,Open Porch _Solar Panels(w/o rafter upgrades) _Carport.= _Cell Tower I Shed _Pavilion, Pole Barn,Canopy _Dock =Gazebo Detached Garage _Boathouse(with or w/o sundeck) _3-Season Porch Other(description: - ) SQUARE FOOTAGE OF STRUCTURE: 1st floor: . 2nd floor: ` Total'square feet: 21CO ADDITIONAL PROJECT INFORMATION: ' 1. Estimated Cost of Construction:$ 1p, w6 2. If Commercial project,what is the proposed use: A 3. Are there any structures not shown on the plot plan? YES NO Explain: (�©M l.�i�c— ��= ►9�'rwC�S To 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 thework is not completed by the 1 year expiration date the permit may be renewed, subject to fees and department approval. 3. 1 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. 1 acknowledge that prior to occupying the facilities proposed I, or my agents, will obtain a certificate of occupancy. 5. 1 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: V LL-L " SIGNATURE: DATE: I� Accessory Structure Application Revised February 2019