application Office Use Only
Permit n: PS1 Cr-D1)^ZC41�
ACCESSORY STRUCTURE
PERMIT APPLICATION Permit Fee:$
Town of Queensbury
742 Bay Road,Queensbury,NY 12804 invoice#: D 3
P:518-761-8256 www.queensbury.net
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Project Location: V:\ E 0 V 2
Tax Map ID #: Subdivision N. ttU ft 9 2O1S
CONTACT INFORMATION: .SOWN OF QUEENSBURY
BUILDING&CODES
e A licaAt:
Name(s): s.
Mailing Address, C/S/Z:
Cell Phone:. Se, ) Z.. Land Line: ( )egs-...otero
Email: • r. '"Qec,Mta. t+V, a Cck
• Primary Owner(s):
Name(s):
..Mailing Address, C/S/Z: \.(2k ,5 %3 etsfsIctcar9 \A. _
Cell Phone: ( ) . Land Line: (
Email:
® Contractor(s):
Business Name: �P�� �J15 _ e - 1431
Contact Name(s): m-- ev-�kt,&ea-
Mailing Address, C/S/Z: 83k GI 1> o^ Aiskolivk A W. MAD
Cell Phone: ( 'I ) 9 3ce3 Land Line: ( SI ) 8c-_9:
Email: ,e. er to cte - Ste,
• Architect(s)/Engineer(s):
Business Name: _ b‘414.1., Z, 1,,s, +t.%& •
Contact Name(s): t8x4A-A) .
Mailing Address, C/S/Z:
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Cell Phone: ( ) Land Line: (51g ) Z- ':'V -
Email:
Contact Person for Building & Code Compliance: j,e--
Cell Phone: (51 ) —ZZt2S, Land Line: ( )
Email: 0 rv►t��ie� CCM\
Town of Queensbury Building&Code Enforcement Accessory Structure Application Revised April 2017
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: AZP,
2nd floor: -
Total square feet:
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$ 3O1 00
2. If Commercial project,what is the proposed use:
3. Are there any structures not shown on the plot plan? YES ,Lid 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.
have read and agree to the above:
PRINT NAME: Cl0 - eR- Pirwvt p?
SIGNATURE: DATE: elf9 ( 0�
Town of Queensbury Building&Code Enforcement Accessory Structure Application Revised April 2017