application — Office Use Only
-- - ACCESSORY STRUCTURE r—
Permit#: 2y
f� M
��t�<<;I 611J PERMIT IG 0 V IE P rmit Fee:$
742 Bay Road,Queensbury,NY 12804 11 voice#:
P:518-761-8256 SEP 15 2020
TOIlMI Project Location: 99 Mannis 12D OF QUEENSBURY
OF
&CODES
Tax Map ID Subdivision Name:
CONTACT INFORMATION:
® Applicant:
Name(s): _Carol Fisher, Jim Underwood
Mailing Address, C/S/Z: _99 Mannis RD/Queensbury/NY/12804
Cell Phone:_(Carol: 518 791-1469, Jim: 518 798-5309 ) Land Line:
_( )
Email: _carolfisher77@gmail.com
Primary Owner(s):
Name(s):_Jim Underwood
Mailing Address, C/S/Z: _99 Mannis Rd/Queensbury/NY/12804
Cell Phone: _(_518 798-5309 ) Land Line: _( )
Email:_iimundo@roadrunner.com
x❑ Check if all work will be performed by homeowner only
10 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)/Engi nee r(s):
Business Name:
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _( )
Email:
Contact Person for Building & Code Compliance:
Cell Phone: _( ) Land Line: _( )
Accessory Structure Application Revised February 2019
PROJECT INFORMATION:
TYPE: ❑ Commercial X Residential
WORT(CLASS:
❑ Deck,Open Porch ❑ Solar Panels (w/o rafter upgrades) ❑ Carport ❑ Cell Tower
❑ Shed X 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: 168
2nd floor:
Total square feet:_168
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$_2000
2. If Commercial project,what is the proposed use:
3. Are there any structures not shown on the plot plan? YES X NO Explain:
4. Are there any easements on the property? ❑ YES ❑ NO
DECLARATION:
1. I acknowledge that no construction shall be commence prior to issua ce of a valid permit and will be.�+,,
completed within a 12 month period. _ '� 13 Cq bo Wavt {Mop J 1
.V
2. Ifthework is not completed by the 1 year expiration date the per it may be renewed, subiect to fe s and
department approval. vV) a -roo �fMCI
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 certificate of occupancy.
I have read and agree to the above:
PRINT NAME: Carol Fisher #do
Accessory.Structure Application Revised February 2019