application t
Office Use Only
ACCESSORY STRUCTURE
Permit#: -
PERMIT APPLICATION \ — ���2 202 C
lim�i of Ourrashun- Permit Fee: $ 1 217
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net Invoice#:
Project Location: C`Ig \• \ aa4oek '2 t
Tax Map ID #: • lb — —Z.C� Subdivision Name:
CONTACT INFORMATION:
• Applicant:
Name( S\W1Cn a - l.cce rdQ)Ar)
Mailing Address, C/S/Z: 1-I' );/-1 C Van()s ed, QuP276 t J�kJ ); �-1
Cell Phone: ( Sig )�Ig.-��t{Q-- Land Line: ( S"15' ) -71J—)F8o
Email: t,Q .Ict.ct ke g plc t i)cC�►'� k11 a��.iv) ,/Y)Ci I.C o'
• Primary Owner(s): V
Name(s): S1na/yt je 4cl ()col)._L C iL€
Mailing Address, C/S/Z: S Tt��n CAVVV e ect, ,eenSi:;,;' , ,/Uc 1 y
Cell Phone: ( S16 ) 8 7R— 140. Land Line: (
Email: ;)VICA cAscn lac,ke C 3 me 11 . -C '\ loctipP j d cicorl tvIct 1. t.e►vN
❑ Check if all work will be performed by homeowner only
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): 1-4 Pt"-) k oSk; f\h. lis propsAi &nc{9pA&.e.(4-f—
Contractor Trade:
Mailing Address, C/S/Z: of '66 wco Cdlc�� e /f ( � £2 dt r2
Cell Phone: ( S(d ) la-z{`-14� 1 Land Line: (
Email: 115p4-`'��'1n �'1� Mai I. Lt: .M ? ( �(`5
**List all additional contractors on the back of this formiNfp W
• Architect(s)/Engineer(s):
Business Name:
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: j )
Email:
Contact Person for Building & Code Compliance:
Cell Phone: ( ) Land Line: (
Email:
Accessory Structure Application Revised February 2019
II r
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 (o e' �
2nd floor:
Total square feet:
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$ LI'SGL
2. If Commercial project,what is the proposed use: //��
3. Are there any structures not shown on the plot plan? YES ( NQ► Explain:
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: 4 i• 1 of 4r&a
SIGNATURE: Chilli DATE: 62 ( 8'6.) ,
Accessory Structure Application Revised February 2019