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application s Office Use Oniv ACCESSORY STRUCTURE Perrnit#: PsST- o'yZ2-20�$ PERMIT APPLICATION Permit Fee:$ 12S Town of Queensbun' 742 Bay Road,Queensbury,NY 12804 Invoice#: P:518-761-8256 www.gueensbury.net Project Location: 2( 14i eil+ ►'��✓1 e- ,V Tax Map ID #a �`�lQ - -1"'� Subdivision Name: CONTACT INFORMATION: ® Applicant: Name(s): -rho,"e,.s Mailing Address, C/S/Z: 2l /J,ti �g.n - dr'✓G 0. --a 6wZ- Cell Phone: 71 ) 75 5"-7 6 1 Land Line: �_) zy.44 Email: e- GC -+ • Primary Owner(s): Name(s): 9F 6 g. .. e Mailing Address, C/S/Z: 2 o' n- Cell Phone: 5/T ) q 3 2 - 31 WI Land Line: �_) A//.4 Email: • Contractor(s): Business Name: . 's r G�� • ^ ^'� Contact Name(s): Mailing Address, C/S/Z: Cell Phone: �_) Land Line: Email: • Arch itect(s)/Engi nee r(s): r `� ;h. Business Name: Contact Name(s): 20($ Mailing Address, C/S/Z Cell Phone:�_) Land Line: Email: Contact Person for Building & Code Compliance: Cell Phone: ( ) Land Line: Email: Town of Queensbury Building&Code Enforcement Accessory Structure Application Revised April 2017 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: D A© 2nd floor:_ 1 Total square feet: 320 ADDITIONAL PROJECT INFORMATION: 1. Estimated Cost of Construction:$ 10 190c7 2. If Commercial project,what is the proposed use: a14 3. Are there any structures not shown on the plot plan? YES NO,Explain: 4. Are there any easements on the property? YES NO DECLARATION: I. 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 thework is not completed by the 1 year expiration date the permit may be renewed, subject to fees and department approval. 3. 1 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. 1 acknowledge that prior to occupying the facilities proposed I, or my agents, will obtain a certificate of occupancy. 5. 1 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: "� r.�-re s J SIGNATURE: --'''�.�-.. r� _._._._ DATE: �7"vy°►� �S Town of Queensbury Building&Code Enforcement Accessory Structure Application Revised April 2017