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Office Use Only ACCESSORY STRUCTURE am RETO -20PERMITAPPLICATIONPermitSteePermitFee:$_!7D Invoice #:__2142 Town of Queensbury 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.queensbury.net Project Location:seln,\\\\p Tax Map iD#;__208.-10 Subdivision Name: p ECEIVECONTACTINFORMATION: i i OCT 29 2019©Applicant:u Name(s):Wilor Waske \\TOWN OF QUEENSBURY Malling Address,C/S/2:62 Richmaacd Wy Wr BUILDINGS COUR Cell Phone:_(Sts _)W444 =3274 land Line:_() Email: *Primary Owner(s): Name(s):Noolicant Mailing Address,C/S/Z:ua Cell Phone:_()Land Line:_() Email: ocheck if all work will be performed by homeowner only *Contractor(s):Workers’Comp documentation must be submitted with this applicationContractorName(s):_Contractor Trade: Mailing Address,C/S/Z: Cell Phone:_()land Line:_() Email: **List all additional contractors on the back of this form ©Architect(s)/Engineer(s): Business Name: Contact Name(s): Mailing Address,C/S/Z: Cell Phone:)land Line:_() Email: Contact Person for Building &Code Compliance:Np CantCellPhone:_()Land Line:) Email: PROJECT INFORMATION: TYPE:Commercial __&Residential WORK CLASS: __Deck,Open Porch __Solar Panels (w/o rafter upgrades)__Carport ___Cell Tower “shed __Pavilion,Pole Barn,Canopy __Dock:__Gazebo ___Detached Garage Boathouse (with or w/o sundeck)__.3'Season Porch __Other (description:) SQUARE FOOTAGE OF STRUCTURE: Ast floor: 2"floor: Total square feet:_520 ADDITIONAL PROJECT INFORMATION: 1.Estimated Cost of Construction:$_OOO. 2.If Commercial project,what is the proposed use: 3.Are there any structures not shown on the plot plan?YES NO Explain: 4.Are there any easements on the property?Yes No. DECLARATION: -|acknowledge that no construction shall be commenced prior to issuance of a valid permit and will becompletedwithina12monthperiod. 2.Ifthe work is not completed by the 1 year expiration date the permit may be renewed,subject to feesanddepartmentapproval. 3.Icertify that the application,plans and supporting materials are a true and complete statement and/or descriptionoftheworkproposed,that all work will be performed in accordance with the NYS Building Codes,local building lawsandordinances,and in conformance with local zoning regulations. 4.|acknowledge that prior to occupying the facilities proposed |,or my agents,will obtain a certificate ofoccupancy. 5.lalso understand that I/we are required to provide an as-built survey by alicensed land surveyor ofall newlyconstructedfacilitiespriortoissuanceofacertificateofoccupancy. |have read and agree to the above: PRINT NAME:Rachacd i sionaTure Qa Un.wed Reblouoy,DATE:toh (201 Accessor Structure Application ‘pevieed Februsmy 2018.