Application Office Use Only
±ZTRUCTURE
PERMIT APPLICATION Permit#: &,; ) 37 7-;011
finrn nd(?uccn+bury
742 Bay Road,Queensbury,NY 12804 Permit Fee: $ 7• Ld
P:518-761-8256 www.gueensbury.net Invoice#: (("0-5
Project Location: I/IueI r+b(}wW-C-o .) f
Tax Map ID #: d2 •S - Z.- Ip Subdivision Name: LE Ut� -
„CONTACT INFORMATION: D
MAY 3 i 2c,i9
• Applicant: n /�
Name(s): MIL r1/ 1C-6r6 —_-rovV OF nn -VV-L ME T
Mailing Address, C/S/Z: -I ►'Yhac aor(DOK u ce
Cell Phone: ( T� ) W - Q'1*-1 Land Line: �)
Email: I �WPhlf�T-DB larn4u- • CcF'y`
Primary Owners :
Name(s): (,1 f 0. k1
Mailing Address, C/S/Z: JLr)LQDbr^c;kOK u e L1(e
Cell Phone: 1 9 ) t-( - 4 I ;�;-1 Land Line: � )
Email: t')ICo Ie ri'1Gdfa}� IS q (Y)O-L- - (--0ry-)
0 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: i
Cell Phone: . Land Line: �)
Email:
"List all additional conkractors kn the back of this form b
• Arch itect(s)/EnKineer(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:
Email:
Accessory Structure Application Reweed February 2019
PROJECT INFORMATION:
TYPE: Commercial X Residential
WORK CLASS:
Deck,Open Porch —Solar Panels(w/o rafter upgrades) _Carport _Cell Tower
Shed _Pavilion, Pole Barn, Canopy _ Dock _Gazebo
Detached Garage C , _Boathouse (withor w/o sundeck) _3-Season Porch
Other(description: Sk S y)-P_J )
SQUARE FOOTAGE OFSTRUCTURE:
1st floor. `l�
21d floor:
Total square feet: ,q a
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$ 3 15�0Q
2. If Commercial project,what is the proposed use:
3. Are there any structures not shown on the plot plan? YES NO xplain:
4. Are there any easements on the property? YES NO
DECLARATION:
I. 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. 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: I^
PRINT NAME: i1'1(L • � cC�r�r t 1
SIGNATURE: DATE:
Accessory Structure Application Revised February 2019