AST-0669-2019 i
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s Office Use Only
r 1 C SORY STRUCTURE Permit#: I& Ste' ��('c(- �,c(
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l� IT APPLICATION Permit Fee:$ = !'2-S Co
of Queensbury e
2 ay��d,��eryfN > 04 . . Invoice#: 07,0
P. 8-761-8256 _www: u ensb .net
TOWN OF QElEFI`fS6URYWow
Tax Map I®.#: Sdbdidlsion Name:. —,
CONTACT INFORMATION: OCT 0 7.2019
Applicant. TOI 1 OF OUE ENSS CRY
Name(s): 13U1?Dlilr;
Mailing Address, C/S/Z: 14
Cell Phone: ) Land Line:.-
Email:
• ' Prima Owrner s :
Name(s):
Mailing Address, C/S/Z: N iL!
Cell Phone:
Land Liner : (cjlg ) jqg .. �1$
Email: •
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Contractor(s):
Business Name: . k=1
Contact Name(s):
Mailing Address, C/S/Z: .
Cell Phone: Lend Line:.
Email:
• Archltect(s)/Enaineer(S):
Business Name:__. ntS)�t � • l> �)" i ;1 . '
Contact'Name(s): .
Mailing Address, C/S/Z: , 28o
Cell Phone: ( ) Land Line:
Email:
Contact Person for Building.&Code',Compliance: ��
Cell Phone:—�--) Land Line:
Email: t1Q 1 t�°odom
Town of Queensbury Building&Code Enforcement Accessory Structure Application Revised April 2017
PROJECT INFORMATION:
TYPE: V/ Commercial Residential
WORK CLASS:
Deck,Open Porch , —Solar Panels(w/o.rafter-upgrades) _ Carport _Cell Towier
Shed r Pavilion, Pole Barn,Canopy i Dock _Gazebo
Detached Garage r Boathouse(With or w/o.sundeck) 3-Season Porch
-Other(description: )
SQUARE FOOTAGE OF STRUCTURE:
1st floor: ;
2"d floor: 161D�
Total square feet:
.180
ADDrrioNAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$ ����•
2. If Commercial projectawhat is the proposed use: Z
3. Are there any structures not shown on the plot plan? YES QVEkplain:
4. Are there any-easements on the property? YES OV
DECLARATION:
1. 1 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 1/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: Liu
SIGNATURE: DATE:
Town of Queensbury Building&Code Enforcement Accessory Structure Application Revised April 2017