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applicationOffice Use Only Permit #:__ AST~D2B 207 ACCESSORY STRUCTURE PERMIT APPLICATION Town of Queensbury Permit Fee:$_[2&>—~ 742 Bay Road,Queensbury,NY 12804 erm Fee:§_[2 P:518-761-8256 www.queensbury.net Invoice #:_2teA\ Project Location:24 Charltin Lows Tax Map ID#:_309,G-2-G Subdivision Name: CONTACT INFORMATION: ©Applicant: Name(s}:fat,+Julie Haack Mailing Address,C/S/Z:vl ben & CellPhone:(S1%)3al-9656 Land Line:_“s 4 Ato Email:Je nichol,6724)-guceai|com «Primary Owner(s): Name(s):halle.Julie Haack Mailing Address,C/S/z:__34 Charla fan?(Jutendrary WaneaCh ,AIF Cell Phone:_(57 )32 epee Land Line:)1asof Email:Dwichals@1@ gual.ce OO Check if all work will be performed by homeowner only ©Contractor(s):Workers’Comp documentation must be submitted with this application Contractor Name(s): Contractor Trade: Mailing Address,C/S/Z: Cell Phone:_().Land Line:_{) Email: **List all additional contractors on the back of this form *Architect(s)/Engineer(s) Business Name: Contact Name(s): Mailing Address,C/S/2: Cell Phone:_()Land Line:_( Email: Contact Person for Building &Code Complianc Cell Phone:_()land Email: Accessor Strutre Appleton se Febuary 2019, oP PROJECT INFORMATION: TYPE:Commercial Xx Residential WORK CLASS: x Deck,Open Porch __Solar Panels (w/o rafter upgrades)__Carport __Cell Tower __Shed ___Pavilion,Pole Barn,Canopy ___Dock __Gazebo ___Detached Garage __Boathouse (with or w/o sundeck)___3-Season Porch __Other (description: SQUARE FOOTAGE OF STRUCTURE: Ast floor: 2°floo1 Total square feet:_400Fisg .ADDITIONAL PROJECT INFORMATION: 1.Estimated Cost of Construction:$_“F000,2.if Commercial project,what is the proposed use:Mor App cable 3.Are there any structures not shown on the plot plan?@)Shed a Lea vite [side oh 4,Are there any easements on the property?Yes ECLARATION: 1.1 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 atrue and complete statement and/or descri 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 [Ave are required to provide an as-built survey by a licensed land surveyor of ali newly constructed facilities prior to issuance of a certificate of occupancy. |have read and agree to the above: Tale Haacle fabian Hoses DATE:(o fo 0 PRINT NAMI SIGNATURE: econ Sate Sppction eid February 2019