application • 1
�- Office Use Only
ACCESSORY STRUCTURE
Permit#: k \ - 8 k.h -- 2Q 2-0 PERMIT APPLICATION
Town ofQW-c-6 y Permit Fee:$ 100-
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.aueensbury.net Invoice#: ��
Project Location: 1 l9"111aAt+YK ±! 0-1 _
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Tax Map ID#: ?�- - Subdivision Name: D
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APR i
CONTACT INFORMATION:
TOWN OF QUEE4�IS�U��
• Applicant: ,,
gUiLoING&C0gES
Name(s): M4± 0 ,
Mailing Address, C/S/Z: (� t�v� ��•v Qr /n I✓ ��
Cell Phone: L{ !S ) � - 09L P;( Land Line:
Email: .(j AFL- Ct
• Primary Owner(s):
Name(s): a,� ZLL
Mailing Address, C/S/Z: 0 A1,4.11LOwne /vr ;
Cell Phone: ('6K ) ;4 -OaO/ Land Line:
Email: ;�C LAk r 0 .;l a A-7 Z,1: �
❑ Check if all work will be performed by homeowner only
e Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): ,f�� a G� S ei lcc-, G
Contractor Trade: vv
Mailing Address, C/S/Z: �� a a A a✓se Pi
Cell Phone: -( Land Line: �7,5 ZW6 _—.5 C_S
Email: a 01 0`6 eL of± o ma's
"List all additional con ractors on the back of this form
e Architect(s)/Engineer(s):
Business Name:
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone:�_) Land Line: S )
Email:
Contact Person for Building&Code Compliance:
Cell Phone: Land Line:
Email:
Accessory Structure Application Revised February 2019
I
PROJECT INFORMATION:
TYPE: Commercial Residential
WORK CLASS:
Deck,Open Porch _Solar Panels(w/o rafter upgrades) Carport _Cell Tower
r 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:
2"d floor:
Total square feet:
ADDITIONAL PROJECT INFORMATIO
N
:
1. Estimated Cost of Construction:$ Z64, ,z#�
2. If Commercial project,what is the proposed use: 8na-`
3. Are there any structures not shown on the plot plan? YES MO Explain:
4. Are there any easements on the property? YES A% O
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 1, or my agents, will obtain a certificate of
occupancy.
5. 1 also understand that t/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: �lj/ rat
SIGNATURE: DATE: G
AmessorV Stlucture Apniicadon Revised februar/2019