application ITECEIPiVErl
Office Use Only
AtdtriA6F4liniutiuRE �j
ti Permit#: Si— C ) 17 ,--Zc) (
PERMIT/ ngATION
Town of( uccnsbury Ors'.:S Permit Fee:$ J V t 00
742 Bay Road,Qury,NY 12804 --
P:518-761-8256 www.queensbury.net Invoice#: I 2---WO
Project Location: 42. OLO 1 3eA L 1 rotor aO
Tax Map ID #: '231-l2 -- '2 - II Subdivision Name: 4.114
CONTACT INFORMATION:
• Applicant:Name(s): Jeer 4 4. `- e4Lett,
Mailing Address, C/S/Z: 82 C 4044'1W 12ZI\4 1\/Gt, eW\AL..El o•1' 1218(D
Cell Phone: ( Si$ ) 89 152I OE r-F Land Line: (
Email: .1EFFl2E7r IONS
• Primary Owner(s):
Name(s): '3 *4 . i 4 /%41°U.c4Ur
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: (
Email:
1Check if all work will be performed by homeowner only
• 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:
**List all additional contractors on the back of this form
• Architect(s)/Engineer(s):
Business Name:
Contact Name(s): cuepa7 17. 0-rtzisS
Mailing Address, C/S/Z: (°► Owe. )ZUL( i et. 6E0(76E) Or 124•3
Cell Phone: ( ) Land Line: ( 61$ ) Wog 6691
Email: c,a-r , @ 1im400. GOF'f
Contact Person for Building & Code Compliance: A?c...44
Cell Phone: ( ) Land Line: (
Email:
Accessory Structure Application Revised February 2019
PROJECT INFORMATION:
TYPE: Commercial x Residential
WORK CLASS:
,__Deck, Open Porch ____Solar Panels(w/o rafter upgrades) Carport `Cell Tower
____Shed —Pavilion, Pole Barn, Canopy Dock —Gazebo
Detached Garage X Boathouse(with or w/o sundeck) *3-Season Porch
_Other(description: )
SQUARE FOOTAGE OF STRUCTURE:
1st floor: 1Oo 62,640)
2nd floor: (431,4. I eCA . Y PA2LI ,z.)
Total square feet: p�Q'.,'
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ II 060 (701...145,e64- .
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? ES NO *Aire. L4L`` t. rf�'1 f
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:
/ (1
•
PRINT NAME: JL7`lfey P7NbLL S
SIGNATURE: 47 I o �- DATE: 3 /11 /2cit ci
Accessory Structure Application Revised February 2019