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application Office Use Only ACCESSORY ST L W F f Act - O9 --2 0k1 PERMIT APPL h .,'(,r( uccnsbury Pe e: $ 1 Z c D 742 Bay Road,Queensbury,NY 12804 JUN 1 3 2019 c' P: 518-761-8256 www.queensbury.net Invpice#1 IQ J tf TO OF QUEENSBURY Project Location: ` V U CODES O©� Tax Map ID #:S�7b-3c8-rol-O�I- Subdivision Name: r��e ?r -1-LE?kC��� CONTACT INFORMATION: • Applicant: Name(s): J do f Sl\ta ' (, he Mailing Address, C/S/Z: $7 (Z\cL�v�,.o►m*. \' ),' - f r, eA'\Slou k)4 0 ,( Cell Phone: ( 'E3 ) 'lctl— �5 ) (JuoAA � t►� (�1� ) �l�oZ 11a3��"1 I/ �41 (��( Email: j Uc1J- C l�la l I �`n -S G? 1 \& CvrA (ks c -- .(5vhea )V9.er)1.4 of j • Primary Owner(s): Name(s): : 1da AA, t" ► S k ��e�. L. . SkOrl Mailing Address, C/S/Z: Ste_ C cw Cell Phone: ( ) Land Line: ( cLLe« Email: ')ECheck 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: 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: 1\C:C).:i(1 Cell Phone: ( ) Land Line: ( ) Email: Accessory Structure Application Revised February 2019 PROJECT INFORMATION: TYPE: Commercial V Residential WOR LASS: 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: 31 0 3 A - 2"d floor: Total square feet: 3-7C) S%W- ADDITIONAL PROJECT INFORMATION: 1. Estimated Cost of Construction: $ $' ,( OCD 2. If Commercial project,what is the proposed use: 3. Are there any structures not shown on the plot plan? YES NO xplain: 4. Are there any easements on the property? YES 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: lJcc& G 'hOn SIGNATURE: DATE: 6 /!3("/ Cl Accessory Structure Application Revised February 2019 ■