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Y ST 6 E ��
ACCESSORY #
PERMIT APPL4T OuAPR 0 4ZQi: '=r -e: $ ��
(o�ti to of CLccn;b NY 12804 U
742 Bay Road,Queensbury,
- 256 www•gueensburv.net TOWN OF QUEEN'i31i'�Ce
P.518-761 8 !WING&COS_ �,� �I? Zor,y+S
Project Location:
?et�, 5'i _( Subdivision Name:
Tax Map ID#:
CONTACT INFORMATION:
• A licant: sv
Name(s): , , Land Line:, _(
Mailing Address, C/S/Z: )RD ��
Cell Phone: �___-)
Email:
• Primary Ownerls):
Name(s):
Mailing Address, C/S/Z: Land Line:
Cell Phone:
Email:
❑ Check if all work will be performed by homeowner• onl
Contractors : Workers' C mp
documentation must be submitted with this application
Contractor Name(s):
Contractor Trade:
Mailing Address, C/S/Z: �- Land Line:
Cell Phone: �1�)
Email:
**List all additional contractors on the back of this form
• Architect(s)IEn ineer s
Business Name:
Contact Name(s):
Mailing Address, C/S/Z: Land Line:
Cell Phone:
Email: r
Contact Person for Building & Code Compliance:
Land Lin
Cell Phone: � �.—.)
Email:
Revised February 2019
Accessory Structure Application
• Contractor(s): orkers' Comp documentation must be submitted with this application
Contractor Name(s): C9.+'3\\+ Li?. �� ..kv
Contractor Trade:
Mailing Address, C/S/Z: OA N avirakl- Aevtc.., r .dro.rr vv \l&. 12) t 8
Cell Phone: ( ) Land Line: ( 1E3, ) 25b - +c,-51?,
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:
• 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
r . A
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 — Boathouse (with or w/o sundeck) 3-Season Porch
Other(description: )
—
SQUARE FOOTAGE OF STRUCTURE:
1st floor:
2'floor:
Total square feet: >, .;)(9
ADDITIONAL PROJECT INFORMATION: a)
a/,
1. Estimated Cost of Construction: $ „Cif 00 J
2. If Commercial project, what is the proposed use:
3. Are there any structures not shown on the plot plan? YES Pi< Explain:
4. Are there any easements on the property? YES J* .
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: rr n) I ��o � ((��``''SIGNATURE: �. >1:67.- DATE:044642 d/P
Accessory Structure Application Revised February 2019