application is Use Only
ACCESSO.
`=ci. PERMIT I ARRN2 2 20,11 Town ofQueensbury
it Fee:$. / �b o
742 Bay Road,Queensbury,NY 12804
P:518-761 8256 www.queensburv' TOWN OF QfJECf�JSgU
ytnv_ ice#: Z � C.�
BUILDING&C%ODP
Project Location: _ ..Sa crirtie(.ne it)rAr
Tax Map ID#: :2 , . _ _ _. Subdivision Name: :.L 6/,land� S Ps
CONTACT INFORMATION:
• :Applicant:
Name(s): (re 6-arlCe :..
Mailing Address,'C/ /Z:. q Tacf t c(-ne .Dntre i ateektsloarr NY 1'OY
Cell Phone: .(S'/S ) 3 (-:Ca3O Land Line: ( ). .
Email re fraJce @ services-ccf'wrlee. •Con.i
• Primary Owner(s)•:
Mailing Address, C/S/Z:
Cell Phone ( ) Land Line: (.. )
Email:
I 1 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)c
Business:Name:
Contact Name(s):
Mailing Address,C/S/Z:
Cell Phone: :( ) . Land Line: ( )
Email: :
Contact Person for Building-&Code Compliance: :I \;c
Cell Phone: ( ) Land Line: (
Email:
IAccessory Structure.Application Revised February 2019
PROJECT INFORMATION:
TYPE: Commercial K 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:
1st floor: 1 CV sf
2"d floor: AO
Total square feet: == 7� SF
ADDITIONAL PROJECT INFORMATION:
1: Estimated Cost of Construction: $ : j COO
2. If Commercial project,what is the proposed 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
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: lD. 6re1Or)l �YAnti .
SIGNATURE: /C DATE: . 2/ c OaaO
Accessory Structure Application Revised February 2019