application Office Use Only
ACCESSORY STRUCTURE Permit#:
PERMIT APPLICATION Permit Fee:$ ict°%
Town ofQuccnsbury
742 Bay Road,Queensbury,NY 12804
Invoice#: 4)-0
P:518-761-8256 www.queensbury.net
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Project Location: /II 1 c cl, Ito i5kry y
FEB 0
Tax Map ID#: 2�j �� -�--1S 4 2019
�J, Subdivision Name:
ENSBURY
CONTACT INFORMATION: tJi t►raG OFFICE Y
• Applicant:
Name(s): ;Taxi/ 5 Sc biher etc.{-
Mailing Address, C/S/Z: 2 5 u i" Sci1ef Fc{'e✓1_ c./ De 41 ,�y I II/8
Cell Phone: ( 6")' ) YG f 1 �l8 Land TLine: ( )
Email:
• Primary Owner(s):
Name(s): S ScAvnec\efi
Mailing Address, C/S/Z: 2 S ii SCIeler decry f1 , 12Q X ForA y i2►i/2
Cell Phone: ( ) Land Line: (
Email: JSC�► ei(),c"t Rile iUUcc:cd , co
• Contractor(s):
Business Name: S )c Cc,
Contact Name(s): -rank R'.1A ILO 0
Mailing Address, C/S/Z: 0 tx X' a q I Cfeue elede ivy)
Cell Phone: ( 61 K ) si= 36i ;3S-zc Land Line: ( ) C zf
Email: el11-c cldc IC co c ;vtctil .4e7; t
• Architect(s)/Engineer(s):
Business Name:
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: (
Email:
Contact Person for Building& Code Compliance: ,rt ' �PAi4
Cell Phone: ( 5 I$ ) Land Line: (
Email: e\i`!-e clock Cc1 c v is i'1 coo'?
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 )( Boathous wit�i or w/o sundeck) —3-Season Porch
Other(description:
SQUARE FOOTAGE OF STRUCTURE:
1st floor: N//)-
2nd floor:
Total square feet: 60,2-
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ / 3`40
2. 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 6¢
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 1/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: 'Te"0-411_ 1{ O
SIGNATURE: DATE: / p