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Office Use Only ACCESSORY STRUCTURE Permit#: PST" Oty 20 2cs PERMIT APPLICATION 742 Bay Road,Queensbury,NY 12804 Permit Fee:$ 125 P:518-761-8256 www.queensburv.net Invoice#: 242,1 Project Location: a�'4(6.9 Pkolite__ a Al% . i 4a801 Tax Map ID #: (3 06—/ • 5 Subdivision Name: CONTACT INFORMATION: • Applicant: Name(s): Rc el 7t C- Mailing Address, C/S/Z: 9.4 cs,q 0`61ol e_ ir4 f 62k.e f igabg4r1 i fJ if 1cL& fp Cell Phone: ( Ifs ) Land Line: ( ) Email: rQbo V3(2-1 i.eJ'e( J m4,_ • Primary Owner(s): Name(s): a0641,k. C4. ��NIA- I t. Mailing Address, C/S/Z: ati b' (2 1 (2.A 1 at4-e ) r1 i( late-c/f Cell Phone: ( j� ) 3'1 -1491'1 Land Line: ( ) s''a,eQ Email: rohe)be-lievPdZ y , Ca*, ',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): Business Name: Contact Name(s): Mailing Address, C/S/Z: Cell Phone: ( ) Land Line: ( ) Email: Contact Person for Building & Code Compliance: A-p p Cell Phone: ( ) Land Line: ( ) Email: Accessory Structure Application Revised February 2019 -*"ems Lemony Salmon Piccata-Healthy Salmon Recipe 10/21/19,1:19 PM PROJECT INFORMATION: ©2ot9 Hearst Magazine Melia,Inc.All Rig Resejve.I TYPE,: Commercial j \j4Residential 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: 2"d floor: ll Total square feet: a X 1 1� ADDITIONAL PROJECT INFORMATION: 1. Estimated Cost of Construction:$ ( 'QO 500 2. If Commercial project,what is the proposed use: 3. Are there any structures not shown on the plot plan? YES ()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: Pelvto e, VPti��r SIGNATURE: '�'""`� �` DATE: lib I� https://www.goodhousekeeping.com/food-recipes/healthy/a46953/lemony-salmon-piccata/ Page 3 of 3 Accessory Structure Application Revised February 2019