application •
Office Use Only
ACCESSORY STRUCTURE �-
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PERMIT APPLICATION Permit#:
Town of Qucensbury
742 Bay Road,Queensbury,NY 12804 Permit Fee:$
P:518-761-8256 www.queensbury.net Invoice#: T�
Project Location: 66 LajCv Q04cz
Tax Map ID #:Soak°h '7'1 , I 3 i Subdivision Name:
f3'1 oz>c l paArret r'-!-
CONTACT INFORMATION:
• Applicant:
Name(s): ( Curl e
Mailing Address, C/S/Z: `J udif a.r �. 1 C A Aicr- S'a/1e/l, Jc ovic (O.
Cell Phone: 919 ) 720 Xg(oI Land Line: ( 9/4/ 76 -
Email: MrsruY phiC? ` Ccm 1 v► tuvtlphi ', () a /. C_v-11,7
• Primary Owners :
Names ) /14hin"forci
Mailing Address, C/S/Z: 7 S(a ale 14411 ortJ koN441 £a. ,i..* ;/1at-,yoyic... 10f60
Cell Phone: ( 9/'-/ ) 72,0 )47C7I Land Line: ( <<j). Z )6) -
Email: (\Ars iv\uitni te. ( Can (-I GilA.c4v14 fah ire (a) a.-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): G cein i,ne / Pn.Arick 1 o to -�--Ck. ,`P, E.
Contractor Trade: shoji, Mc1iula r 40Y142-5 I G KI -S ! z dos Iat --CPC kro_S.
Mailing Address, C/S/Z: Q-t- ,Q G(i Z vi. Perk /6"52_ tacc,(.c.ee- ti 62-u .e.em lo way
Phone: ( Sly' ) `793 -- ( 5id' ) 3c, I - Z7'2,0
Email: Pre ,� CrAii-Jedin f me con', Cell
**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: ( ) L nd-L-i-ne
Email: 1 , v,%` f;:1
Contact Person for Building & Code Compliance:I !HI I II e L nr ,n ,i,
Cell Phone: ( ) Landl Line: ( Llu [:'i
Email: -a1ii•e 1- 4-E S
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Accessory Structure Application Revised February 2019
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PROJECT INFORMATION:
TYPE: Commercial Residential
WORK CLASS:
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:
1st floor: I 050<o
2nd floor.
Total square feet: C 6
0
ADDITIONAL PROJECT INFORMATIION: i
1. Estimated Cost of Construction:$ STN v �d.J }� Sit, O )
2. If Commercial project,what is the proposed use:
3. Are there any structures not shown on the plot plan? YES Explain:
4. Are there any easements on the property? ES NO Pc.,A_0c.d‹. Lame _ 313 Mu tvve.
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: ()k CA iJ M WrzGYv' 1 (coal"..1114140.4.c A o(
SIGNATURE: -At/X./tiler-Q. DATE: G I a.3 2(2c)
Accessory Structure Application Revised February 2019