application Office Use Only
Permit#: A,S1- Ot-°CP -?°(
ACCESSORY STRUCTURE
PERMIT APPLICATION Permit Fee:$ t)0
Town of Clyeem-bury (1:4 It --
742 Bay Road,Queerisbury,NY 12804 Ir*oice# 5
P:518-761-8256 www.queensbury,net
1'1 OCT 23 2018 ;
Project Locafion: o ;
Tax Map ID#: 21‘ o Subdivision Warne: T1I OP C.,LC- 14 1 PD
CONTACT INFORMATION:
• Applicant:
Name(s): obTH1LL ;LA-t LDE
Mailing Address, C/S/Z: q rno P -T S ID 6- alik a-14-56-4-1 pl
Cell Phone: (C( ) -71 3 Land Line: { ) -
Email: co 01-t-kILIM)o-k I Li)EiLst.-)1 G-ryA AIL., C-4 re\
• Primary Owner(s):
Name(s): SGrotr
Mailing Address, C/S/Z:
Cell Phone: ( Land Line: (
Email:
• Contractor(s):
Business Name: s' m 6
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: I Land Line: (
Email:
• Architect(s)/Engineer(s):
Business Name:
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: I Land Line: (
Email:
Contact Person for Building& Code Compliance: -30£
Cell Phone: ( C11 ) 19. - 1933 Land Line: ( ) 167 b 2-6
Email:
Town of Queensbury Building&Code Enforcement Accessory Structure Application Revised April 2017
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PROJECT INFORMATION:
K/
TYPE: Commercial ^\ Residential
WORK CLASS:
_X 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 sundewk) 3'9easonPorch
Other(description: )
SQUARE FOOTAGE OF STRUCTURE:
lotf|oor:
2"0 floor:
Total square feet: /_�(}
ADDITIONAL PROJECT INFORMATION:
l. Estirnated Cost ofConstruction: $ —/ 0 » 0
Z. 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. 1 acknowledge that no construction shall be commenced prior to issuance of a valid permit and will be
completed within a 12 month period.
2. |fthework is not completed by the l 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 [odes' local
building laws and ordinances, and in conformance with local zoning regulations.
4. | acknowledge that prior to occupying the facilities proposed ), or my agents, will obtain a certificate of
occupancy.
5. |also understand that|fiwe are required tmprovide an as-built survey bya licensed land surveyor ofall newly
constructed facilities prior to issuance of a certificate of occupancy.
| have read and agree tmthe above:
PRINT NAME: H LZ L]'
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C�NS}GNATURE OATE'`' '