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applicationOffice Use Onh ACCESSORY STRUCTURE .AST Od2e-2029 PERMIT APPLICATION Permit2 Town of Queensbury Permit Fee:$_200 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.queensbury.net Invoice #:2225) Project Location: YOJoha CZennclon Ke). Tax Map ID #:IQ2\O-LAA Subdivision Name: CONTACT INFORMATION: e Applicant: Name(s):___eho Seheoeder Mailing Address,C/S/Z:_42 JIphu C¥en lou Kd. Cell Phone:_(78_)70%3733 Land Line:_(_——~}— Email:__ww$auto Cogrcer/s Ae «Primary Owner(s): Name(s):3AM E Mailing Address,C/S/Z: Cell Phone:_()Land Line:_() Email: (A 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: Accestory Srutre pation Revised February 2018, PROJECT INFORMATIO! TYPE:____Commercial Y Residential WORK CLASS: vtDeck,Open Porch ___Solar Panels (w/o rafter upgrades)__Carport __Cell Tower __Shed Ve:n,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:25Z ADDITIONAL PROJECT INFORMATION: 1.Estimated Cost of Construction:$__Ya00 °* 2.If Commercial project,what is the proposed use: 3.Are there any structures not shown on the plot plan?YES Z{O>Explain: 4.Are there any easements on the property?yes iD DECLARATION: 1.|acknowledge that no construction shall be commenced prior to issuance of a valid permit and will be completed within a 12 month period. 2.Ifthework 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,|acknowledge that prior to occupying the facilities proposed |,or my agents,will obtain a certificate of occupancy, 5.lalso understand that Ive are required to provide an as-built survey by alicensed land surveyor of all newly constructed facilities prior to issuance of acertificate of occupancy. Ihave read and agree to the above: n_Sep,PRINT NAME: SIGNATURE;,DATE:_/- 227 > 2028 Aecesony Structure Applation Aevieed February 2018