application Office Use Only
ACCESSORY STRUCTURE - 20 z�
PERMIT APPLICATION Permit#:
rows ofCZccnsbury Permit Fee: $ n e 40
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.aueensburv.net Invoice#: 2g
Project Location: 3 III I n J .
Tax Map ID#: lb- 1 —9-
Subdivision Name `'
1
CONTACT INFORMATION: l JUL 31 2020
• Applicant: (Lop_9F Ot�Elri S�:IJRY
Name(s): G,rv» t. &) `&c �' m \r.lL Dim ( 01)7S
f � t--
Mailing Address, C/S/Z: � \-\ 1Vir) ' &ckifF t-'I 1 C C,:k - zq,33
\Cell Phone: (S ) Land Line: ( )
Email: t Ct Cv� k) ctirf\PA\ i CcVM
• Primary Owner(s):
Name(s): ¶2 Ed U
Mailing Address, C/S/Z: 103 -r-,15 t ,0 • I ?V
Cell Phone: (Os ) a� -- 5�3 Land Line: ( ,
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Email: . rv-N 'KAUT cm. c M Let
❑ Check if all work will be performed by property owner only
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): Gt rv1ro FAA ( cob c - S L — goy143, &vvtu
Contractor Trade:
Mailing Address, C/S/Z: � 3 /i-yyd7L- / 6:-rG- /.1 /G/1a / 53
Cell Phone: (51w j 365- ® 73 3 G Land Line: ( )
Email:
**List all additional contractors on the back of this form
• Architect(s)/Engineer(s):
Business Name: ' Wal(t 4,M S 4c (A) ii tilv fl ?j(qA)6-eS
Contact Name(s): rOAA—KN 'ju. l‘ 1Aiv\S
Mailing Address, C/S/Z: G-, ,! -~i,
Cell Phone: ('���- ) - ( ' lI 6 Land Line: (SIT ) (0 — 7 D r
Email: PA tiD Op to 1 /,aAr?S 42A9 (.vl Al ireeS ! Cam
Contact Person for Building & Code Compliance: VI Mscxc-rim a' bl 61 c
Cell Phone: ( ) Land Line: (
Email:
Accessory Structure Application
Revised January 2020
i
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): ACI al Al Uc)d \ roc.`\kk.-\ 2rz ErccAk_ \
Contractor Trade: ---)(C V.18-� tom'
Mailing Address, C/S/Z: IA L 1 C t c AG C(A) G-�'teiff,,lc) C(c. '�'`� . 1 Z
Cell Phone: ( ) Land Line: (
Email: (10 0A-6/\ -0100 , C.C)•rvr
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): S Cer &r'c 4Z, (A),
Contractor Trade: VWSOR)
Mailing Address, C/S/Z: 1,(3\ \ncl antV 21 ?yolk) )JIM) Iv '( / 7
Cell Phone: (51i ) II'VQ- % Land Line: ( )
Email: Ct-�ME tt C C rvy\AA\ ,cc9,,-..
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): ?1,1QWETLC COMSi-CU-6o/0 L —C._,
Contractor Trade: C( n S
Mailing Address, C/S/Z: 3 G G1- &—k) 1 a tom('i A l c IJ C-(r- )zc '3
Cell Phone: i4 ) `�1 ' 1 j 15 Land Line: ( )
Email:
• 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:
• 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:
• 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:
cessory Structure Application Revised January 2020
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
V Detached Garage Boathouse(with or w/o sundeck) —3-Season Porch
—Other(description: )
SQUARE FOOTAGE OF STRUCTURE:
1st floor: 1 6 5(0
2nd floor: 1.3
Total square feet: 3 ioG
ADDITIONAL PROJECT INFORMATION:On
1. Estimated Cost of Construction:$ (-10 ( DOO
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 buildinglaws
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: !1W l iT /
SIGNATURE. ~ ^ _ DATE: 9-.0? 020020
A a,,,Aty �/%r2,
Accessary Structure Application Revis
ed January 2020