AST-0461-2020 Office Use Only
I` ACCESSORY STRUCTURE
' - f Permit#: AST Orbl ' 2k32..o
PERMIT APPLICATION
Town of Queensbury
742 Bay Road,Queensbury,NY 12804 Permit Fee;$ .1 `�-
P:518-7614256 www.queensbury.net Invoice.#:� .�j(fl
. . . . ..
Project Location: 10.r QOC kr 1 L{,is f c 0_ DI� r� L�
Tax Map ID.#: 0S0? / 1 I 3. . Subdivision Na
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CONTACT INFORMATION:
YCWN O�QUE BURY
• A plicant:.
�COlL► tni{; �r'C� S
Names I \ \\ c .L0rl51-1Uc .Lc —
Mailing Address, C/S/Z: . 51 C&o c c \ii 1 ..0cLa -1-\--txdsc,(A c «5, 1,?\:?zci :. .
Cell Phone:. (51 )02(q- F7a q.. Land Line: (31 ): 7q g-o33
y it P_<�n Con.5 ���-��D co. ,Email: C (�'1C� 2.: @ ht
• Primary Owner(s) (�
Narne(s) • KO►m r`\e-e :.
Mailing Address,.C/S/Z: . . : . ::
Cell Phone: Land Line:
Email:
D.Check if all work will be performed by homeowner,only
• Contractor(s): Workers' Comp documentation must be submitted with this application
Conti-actor;Name(s):. .. � 1\ p. eon s rcKC* on
.Contractor Trade: Ge n e r-
.Mailing Address, C/S/Z: 51 L(ZCL Roo cQ .H 1cc ( LS
Cell Phone:. .(5L .g .70.q. Land Line: .( I :) 710R'- 3.
:Email 1 l OL- @_ C
**List all additional contractors on the back of this form.
• Architect(s)/Engineer(s):
Business Name: 3-a-r n (
Contact Name(s): I v nm ._C r C7E:if
Mailing Address, C S Z: .1A: East .\i&ZS�'i.►n6-(Zyr St .. (: -r s Fa_((S . N la go
Cell Phone: ( ) - Land Line:: : ( 5/?. .) '7902 ".a c'z,:. .
Email: .
Contact Person for Building & Code Compliance: - 10 1 kV"
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Cell Phone: ..(,51 ). 01� `�. .pc(. Land Line: ( )::
Email:-tOm Eli% c.. )()r,v15 '1_c`FIon
Accessory Structure Application Revised February 2019
s
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: 07�,g. nem°th'I/ GLIB ""-J�G: Z-cY
Get 6 5�' ti-, p.Q,c� .5 D f]if-L
2"d floor: d ' S�G i t cz_h d
Total square feet:
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$ Do 0
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 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: QIL S , R-110 re.Gk�'
SIGNATURE: 0.../LAA..ct,,, A - C�� 7'� DATE: " Co c9Uo20
Accessory Structure Application Revised February 2019