application •, ice Use Onl
ACCESS( RRateR p rmit#: =
PERMIT LIGATION
Town ofCZueensbury JUN 12 2019 -rmit Fee: $ 13-' °O
742 Bay Road,Queensbury,NY 128013 L(�j
P:518-761-8256 www.queensbur net7-OWN OF ENSBURY I voice U: I l
BUILDING ••• CODE.
Project Location: 1 1 Mr IJYIAA/I VC .l—
Tax Map ID #: LAO. ) 5-•1 -\2-- Subdivision Name: Mot,el4Pr s COU'l• 11•
CONTACT INFORMATION:
• Applicant: fp"
Name(s): tCAkCI A� �,a .c-2 6re o �1
Mailing Address, C/S/Z: 'I'1 }lk,p i►r'S CAIN4 n• ID Id.k,e.aS191,0N AM IZ)1'n
Cell Phone: (S)8 ) G 3a- 373L( Land Line: ( - )U -
E m a i l: YV1 t c,e_j9 re..e,vto NV) gvl a-a, cbm
• Primary Owner(s):
Name(s): ' ?clA.su.j ce 6- .vw k
Mailing Address, C/S/Z: 11 AU&A4rs Ovvuw, ✓l• I,I.QJASt M/ud- i ? 4
Cell Phone: ( S)8 ) 43a- Land Line: ( )
Email: 1M,t'ct-e—Pq nc.e.A 1 qt0 CPS 5mo:a. !D n�
❑ Check if all work will be performed by homeowner only
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): ii) f&mck-Q. r C:ortvu14e
Contractor Trade: 1/VL(SY.
Mailing Address, C/S/Z: 3v11 P Ct • 'Gm vat YIAI
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Cell Phone: ( ) Land Line: (50 )
Email:
**List all additional contractors on the back of this form
• Architect(s)/Engineer(s):
Business Name: Gn o w4- P.E
Contact Name(s): E,N
Mailing Address, C/S/Z: 14- EvYy 1 . GlimA G V1k. 1?'01
Cell Phone: ( ) 1 Llt-I_&.41 I Land Line: (
Email:
Contact Person for Building & Code Compliance: LJ 6e4'---
Cell Phone: ( `> i ) 3101- )l L-0 Land Line: ( - ) -
Email: -
Accessory Structure Application Revised February 2019
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): b K)d 'k
Contractor Trade:
Mailing Address, C/S/Z: I OOLitwood b v. s•GL 3 AA- 12.10-3
Cell Phone: ( Sl8 ) 1 (-1,U_ 3-r) Land Line: ( $ )
Email:
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): tie �ti..e CeA,v 4v Plu ► .be,� C1)Oa(,oc -t�Pivr to
Contractor Trade: 1 v.
Mailing Address, C/S/Z: 3 Iw S+. &u a_.e,,ti, YL, 1 Z 'Oy
Cell Phone: ( 5)43) 2"Z,Z- 3q0g Land Line: ) —
Email:
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): (ESL -6-v -SCA fit v� 4 11wvaL-t.3 LI_(°�
Contractor Trade: 1 ov,
Mailing Address, C/S/Z: 'erg c� � 1 . �u �• 1 ZU�b
Cell Phone: ( ) Land Line: ( i' ) Sofa-- lG4 3
Email: I r\rz,C- sl Icx.ndscap lc . ConA
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): _
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: ( )
Email:
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): _
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: (
Email:
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: (
Email:
Accessory Structure Application Revised February 2019
a
PROJECT INFORMATION:
TYPE: Commercial Residential
WORK CLASS:
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: a)LI
2nd floor: "(N'0
Total square feet: SC)y
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$ �UCX)
2. If Commercial project,what is the proposed use: 1^.1 O
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: " . J( ,..0€.v10 lit)Y
SIGNATURE: DATE: (P I I I
Accessory Structure Application Revised February 2019