application Office Use Only
ACCESSORY STR - P ,. 1 ---ax-j(ce
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PERMIT APPLIC 4 ( p si m tl e:$
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742 Bay Road,Queensbury,NY 12804 lij Inuo �`#
P:518-761-8256 www.queensbury.net AUG �Q i��
1 G '1 N O!- QUEEN BU
Project Location: CI St, A N C L A t t�it N G& F2 ,.�
Tax Map ID#: Z"r S P i s - 2 - (1 Subdivision Name: 3-0 N N CLEN Do t R p
CONTACT INFORMATION: ��e SFb perii-re + S
12c: 3Yv-a-ci?
• Applicant:
Name(s): FooTH I LLS RutthE Ks — SoE LE u c.i
MailingAddress, C/S/Z: c1 Mow iAINsIDE bR• C %6E: NS t'i 1.01 12,1c11
Cell Phone: ( c t g ) ici t +lq 3 Land Line: ( ) -19 G-35-2-0
Email: Fo v T tt t LLS tau u- P 5 N`t € n IL Cc, iv\
• Primary Owner(s):
Name(s): S A M e
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: ( )
Email:
• Contractor(s):
Business Name: SA m6
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: ( )
Email:
• Architect(s)/Engineer(s):
Business Name:
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: ( )
Email:
Contact Person for Building & Code Compliance: 3b f LE u c
Cell Phone: ( S t t ) /9 1 - t 133 Land Line: ( ci g ) 1 c ( 3 s 2 0
Email: Foo7H1LLi iLDE rJ1 &OAAIL . Corn
Town of Queensbury Building&Code Enforcement Accessory Structure Application Revised April 2017
PROJECT INFORMATION:
TYPE: Commercial Residential
WORK CLASS:
A Deck,Open Porch Solar Panels(w/o rafter upgrades) Carport Cell Tower
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: I 9 Z--
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$ . O 0 L
2. If Commercial project,what is the proposed use:
3. Are there any structures not shown on the plot plan? YES Explain:
4. Are there any easements on the property? YES
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 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. I acknowledge that prior to occupying the facilities proposed I, or my agents, will obtain a certificate of
occupancy.
5. I 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: TO S € P t-t 4
SIGNATURE: DATE: 2
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Town of Queensbury Building&Code Enforcement Accessory Structure Application Revised April 2017