application Office Use Only
ACCESSORY STRUCTURE
�t f PERMIT APPLICATION Permit#: �S, b ZO 1 a Lail
Town of Quecnabury Permit Fee:$ ?j
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net Invoice#: 115
Project Location: 35 oz6 R Ve [�
Tax Map ID#: 30 1S ; / 1 1 TA Subdivision Name: AYA
CONTACT INFORMATION:
• Applicant:
Name(s): E64 5t1 tdA
Mailing Address, C/S/Z: j'14rn4 „Le, Qgv idIESOV
Cell Phone: (5)c ) 3 ,J 0g5 ,, Land Line: (S'1�G ) -9 2) '3c,
Email: Sm ►tN5 TQL( -) n 6,1 t5 1-61. heat
• Primary Owner(s):
Name(s):
Mailing Address, C/S/Z: AikkG
Cell Phone: ( ) Land Line: (
Email: /
lI Check if all work will be performed by homeowner only 3 IE C [E O W
• Contractor(s): Workers' Comp documentation must be submit ithAtiOspyiti
Contractor Name(s):
Contractor Trade: TOWN OF QUEENSBURY
Mailing Address, C/S/Z: BUILDING &CODES`
Cell Phone: ( ) Land Line: (
Email:
**List all additional contractors on the back of this form
• 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: Av 1i
Cell Phone: ( ) Land Line: (
Email:
Accessory Structure Application Revised February 2019
~
-
PROJECT INFORMATION:
TYPE: [urnrnercia| ^' Residential
WORK CLASS:
Deck Open Porch Solar Panels (m/o rafter upgrades) Carport Cell Tower
Shed Pavilion, Pole Barn,Canopy Dock Gazebo
' Detached Garage Boathouse(with or w/o sundeck) 3'SeasonPonch
Other(description: )
SQUARE FOOTAGE OF STRUCTURE:
���
1stf!oor: /^�c/�'
Z"^f|oor:
Total square feet: IA —
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost ofConstruction:$
Z. |f 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 pnnpert 'illYES °/
DECLARATION:
|. | acknowledge that nu construction shall be commenced pr�orK issuance ofa valid permit and will be
completed within a 1Inmonth period.
2. lfthevvork is not completed by the 1 year expiration date the permit may be renewed, subject to fees
and department approval.
3. | 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. | acknowledge that prkor to *ccupyinQ the facilities pro9oaedh, or my agents' will obtain a certificate of
occupancy.
5. (also understand that|/me are mequ�red to provide an as-built survey bya licensed land surveyor of all newly
constructed facilities prior tu issuance ofa certificate ofoccupancy.
| have read and agree to the above:
PR|NTNAME:
SIGNATURE: DATE: �
Accessory Structure Application Revised February mm