application silliW Office Use Only
ACCESSORY STRUCTURE
* Permit#: 41rSi--0210 - 2.Z l°l
PERMIT APPLICATION
Town ofQuoenshury Permit Fee:$__l't
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net Invoice#:
Project Location: 6 k t ( S 4fle9 SO"iO 6)4 c'"st,A -3 0
/ .3° t3
01 S 3 0 3 / •- 3 b ��c�'� 4,fis/ S $
Tax Map iD#: Subdivision Name: �
CONTACT INFORMATION:
• Applicant.
Name(s): A- j 4 Na-,-i5j
Mailing Address, C//Z: 6 k�dffS / i rani iyI (2��c�,4sfi,1 NY /2r 6
Cell Phone: ( 57 ) 6 g3- ? VC( Land Line: ( jr"7 - ) 798- `f/9
Email: 3.---zitvvibs 4136 @) 4e r h,149 A
• Primary Owner(s):
Name(s): €.v4•vrt.e 1- i)rr ta;e/ ever-1 $
a . �
Mailing Address, C/S/Z: (� � afCS 4 la-- S''u_,.i et-/ Cs?,A-czv‘s ,,i � AT /2 i6
Cell Phone: ( S 7 6 ) 6 3 K- YYS1 Land Line: ( 5 '8 ) 7 9 ff- I/99
Email:
C2tleck if all work will be performed by homeowner only
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): 5/ S7 e-II
Contractor Trade: 01^es L 5 S
Mailing Address, C/S/Z: Gk5/ 51- P 1,,,✓s £/ 4„.K /A/Y /2827
Cell Phone: Land Line: ( Sfr ) jD 35 - 3e)55
Email: s+m Q Y ri koo , Co v„
P
**List all additional contractors on the back of this form
• Architect(s)/Engineer(s): E C E 1 NW E
Business Name: tJ —"1
Contact Name(s): d ; APR 2 2 26 ._.
Mailing Address, C/S/Z: 1 d I —
Cell Phone: ( ) Land Line: ( TOWN OF OUEENSBURy
Email: y LU11_:D—NC 8 CODES )
r
Contact Person for Building&Code Compliance: Aro tc ant'
Cell Phone: ( ) Land Line: ( )
Email:
Accessary Structure Appl"acataora Revised February 2019
PROJECT INFORMATION:
TYPE: Commercial Residential
WORK CLASS:
D ,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: / /
2 floor:
Total square feet: /9. 2
ADDMONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$
/ (tf 0 ociD
2. If Commercial project,what is the proposed use:
3. Are there any structures not shown on the plot plan? YES NO Explain:
4. Are there any easements on the property? YES NO
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: e-/v/C_ 4/1/0
SIGNATURE: DATE: "V.;
Accessory Structure Application Revised February 2019