application Office Use Only
ACCESSORY STRUCTURE
PERMIT APPLICATION •
Permit#: CST' DNA,- ZO?�
Permit Fee:$ I �J
742 Bay Road,Queensbury,NY 12804
P 518 761 8256 Invoice#:. ... (a.
Project I;ocahonc / `: C
iy
Tax Map ID#: 29 Z f'� 4-7 Subdivision Name:
CONTACT INFORMATION:
• A lica_nt _.
Name(s): .� h _ _
Mailing Address, C/S/Z: 1 3 e �� Lk: / O
Cell'Phone: (:5?$ OS'en a70W6"YenEd Line: � )
Email: & e tfS2. 'y,44ob.e9 _
• Primary-Owner(s):
Mailing Address, C/S/Z: /3 ea, r A / /Z '
Cell Phone (` ) '71/-.Pa?07 67 7fg--709z Land Line
Email l� � � ye
Check if all workwill 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:._
( ) -- Land Line: ( ) yam ^
Cell Phone:- - - - -
Email: . �Q�� .._�.� \\\
**List ,-"-•;� �� ��� is .r--�"���
List all additional contractors on the back of this form : �
• Architect(s)/Engineor(s): JS
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:
Revised February 2019
Accessory Structure Application
PROJECT INFORMATION:
TYPE: Commercial ,/ Residential
WORK CL •
De —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: Y / O' q "-.i9/40 0
. SQUARE FOOTAGE OF STRUCTURE:
1st Tloor:
2'floor:
02?�
Totai square Teen, i,
ADDITIONAL PROJECT INFORMATION: U
��
1. Estimated Cost of Construction:$ �
D
2: It Commercial project,what is the proposea use:
3. Are there any structures not shown on the plot plan? YES NO Explain:
4. Are there any easements on the property? YES
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
,Df 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:
2.RINT NAME: ti /r 7 o✓1�L
SIGNATU . DATE: /D/ a€)
Revised February 2019
Accessory Structure Application