application Office Use Only
ACCESSORY STRUCTURE 4 oul2o Zc��c�
Permit#: /
PERMIT APPLIC TION -----
Trnvn of llyeen.+bury E C Wrr dU
742 Bay Road,Queensbury, NY 12804
P: 518-761-8256 www.queensburv.net SUN , ifioi l(o 2S
Project Location: .576 'OF QUF.cfVbi~J' fly
UIL►DING t COUPS
Tax Map ID #: 2-- S 2 Su ivisiori"N • .-ah N e(e,,e1o,, e25i-damS
CONTACT INFORMATION:
• Applicant:
Name(s): fcio1L'(JS Pu ►Lc4rL4
Mailing Address, C/S/Z: q 0 Q ✓t' P►N7Ie 4.,47 ./1/
Cell Phone: ( ) -7 9 4.-3 5 a Land Line: ( )
Email: Fool-4, 1(s 131 of N Y• GA^All
• Primary Owner(s):
Name(s): A
Mailing Address, C/S/Z:
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:
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:
Cell Phone: ( ) Land Line: (
Email:
Accessory Structure Application Revised February 2019
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PROJECT INFORMATION:
TYPE: Commercial Residential
I
WORK CLASS:
eck, Open Porch _Solar Panels(w/o rafter upgrades) _Carport _Cell Tower
Shed _Pavilion, Pole Barn, Canopy _Dock _Gazebo
1 _Detached Garage —Boathouse (with or w/o sundeck) _3-Season Porch
Other(description: )
SQUARE FOOTAGE OF STRUCTURE:
1st floor: 9 Y I t.
2nd floor:
Total square feet: 2`-/L/
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ ,C, 0 ,
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:
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: 3, P
PRINT NAME: .1.0S'el A G- e,.., c r
SIGNATURE: , 0dip-I, /5,te,e..4._ DATE: 7- /3 /9
IAccessory Structure Application Revised February 2019