application Office Use Only
='" ACCESSORY STRUCTURE
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PERMIT APPLICATION Permit#:
Town of Queensbury ✓
Permit Fee: $ PO(
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net Invoice#: t ��
Project Location: 9-SA-hex \} LLa), 1a O*
Tax Map ID #: 30a �'% � P Subdivisio lame° _ es
CONTACT INFORMATION: APR 7 q i$' S12 1
• Applicant: uRy (?ccr
Name(s): fiand _A- SLOSan ° I E
Mailing Address, C/S/Z: t l Ph 1/\)
Cell Phone: ( 51,q, ) 'I° - toss Land Line: ) 1ik3-q l40
Email: CGI.uus" 115kc . Ct�vr,
• Primary Owner(s):
Name(s): MCSL Lic $f 4 ,di i v Ilk /Ar'
Mailing Address, C/S/Z gyIC? ihu,k1
Cell Phone: ( ) Land Line: (
Email:
❑ Check 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: *e J
Cell Phone: ( ) Land Line: (
Email:
**List all additional contractors on the back of this form
• Architect(s)/Engineer(s):
Business Name:
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: (
Email: ff
Contact Person for Building & Code Compliance: i � �
Jel/
Cell Phone: (9 ) /®/�J_7 Land Line: (57 ) 7 13- 71 f e,
Email: Alite 6/44 .f4-A-7 ccz),./a
Accessory Structure Application Revised February 2019
PROJECT INFORMATION:
TYPE: Commercial )( Residential
WORK CLASS:
Deck, Open Porch Solar Panels(w/o rafter upgrades) Carport Cell Tower
XShed 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: \1p%
2"d floor:
Total square feet: \\.0%
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ 1000,
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? NO
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: i6lOQ \ -Tcu- cap\totem �kaLn \Ci\- OilfL
SIGNATURE: • `� 'A \t��'1P DATE: \�
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Accessory Structure Application Revised February 2019