application Office Use Only
(111A2' ACCESSORY STRUCTURE
PERMIT APPLICATION Permit#: .ArS� OkkoZ'Zp ‘1
Town of(Zuccn..hury
Permit Fee:$
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net Invoice#: 111111
Project Location: )k a\ny-wickrAca q.af
Tax Map ID #: Subdivision Name:
CONTACT INFORMATION:
• Applicant:
Name(s): e H LIS 771.) HALTMa�
Mailing Address, C/S/Z: /(p Svnu,uySin E _ UE=e-W�v i,�0 /U
Cell Phone: ( ) 74/6, - 3778 Land Line: (
Email:
• Primary Owner(s):
Name(s): p E /45 A Pal C Nr
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): re2-t A..1 LAS Sin
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: ( 5)b ) Lo Y3 -
Email: Fr,Q 7F4-NUSHEfs'TOP. C'_Qay
**List all additional contractors on the back of this form
• Architect(s)/Engineer(s):
Business Name: i•t�Pr
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: (
Email:
Contact Person for Building & Code Compliance: ,-,r
Cell Phone: ( ) Land Line: ( )
Email:
Accessory Structure Application Revised February 2019
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PROJECT INFORMATION:
TYPE: Commercial i( Residential
WORK CLASS:
_Deck,Open Porch Solar Panels(w/o rafter upgrades) Carport Cell Tower
S, 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: 1 z. )( 2-0
2nd floor:
Total square feet: 0
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$ 5'J •C)".
2. If Commercial project,what is the proposed use:
3. Are there any structures not shown on the plot plan? YES NO plain:
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:
SIGNATURE: DATE: 7/g)l C/
Accessory Structure Application Revised February 2019