application ,
,� Office Use Only
`,` ACCESSORY STRUCTURE
4,01
PERMIT APPLICATION Permit#: t�‘ " CT — 2 2-0
town of Qee sbury 15
Permit Fee: $
742 Bay Road,Queensbury,NY 12804 c,
P:518-761-8256 www.queensbury.net Invoice#: 2`I0
-Project Location: 11 6-Ie1 rind__ 61- _,
Tax Map ID #: 20/, /2— / (. Subdivision Name: L I b-a-- e J
CONTACT INFORMATION:
• Applicant:
Name(s): lD. ay.c, lZY-cu l,e-Lk
Mailing Address, C/S/Z: t\ I Nifw\c- CAr-ci e A0 ., n . 12.1Uc-(
Cell Phone: ( fit Y ) ale 1- yg3 Z, Land Line: (5 Y ) 149 2—(1z Z
Email: 7)d,awtb ED/lo er1 viAe0/1 -itvcces a coo"
Primary Owner(sL r
Nare(s): ,vrZ
'V=:!ing Address, C/S/Z:
Cell Phone: ( ) _ Land Line: j )
FAnail:
❑ Check if all work will be performed by homeowner only
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): '61.,,yeA Skop
Contractor Trade: gha,A s t& U sr.
Mailing Address, C/S/Z: (r $ ( 3fi3-{. 41, 1 I-A fin , /ay. I2-3'Z 7
co Phone: ( )_ Land Line: ( ,578 ) le39- WS-S— _
,Email: 51/,et-t0 * 10c jehry . caw.
• **List all additional contractors on the back of this form
• Architect(s)/Engineer(s): ���". 'n
Bus!ness Name: ,
Contact Name(s): �` "t
J
- lIri A: ng Address, C/S/Z: s ° r I
Cell Phone: ( ) Land Line: , TnIN;)i OF 01 jE ,s Tt I
E r1ail: ___ BUILDING C r 1
Contact Person for Building & Code Compliance: DtpcoVce,..n�
Cell Phone: ( ) Land Line: ( )
Email:
Accessory Structure Application Revised February 2019
s,
PROJECT INFORMATION:
TYPE: Commercial X Residential
WORK CLASS:
Deck, Open Porch _Solar Panels (w/o rafter upgrades) _Carport _Cell Tower
4('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: NO 5,Ft
2nd floor:
Total square feet:
ADDITIONAL PROJECT INFORMATION:
oo
1. Estimated Cost of Construction: $ ,4/U7�O' -
2. If Commercial project, what is the proposed use: /�//(4
3. Are there any structures not shown on the plot plan? YES l✓ Explain:
•
'4. Are there any easements on the property? YES 460
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 the work is not completed by the 1 year expiration date the permit may be renewed, subject to fees
and department approval.
:s. 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: Pc .tjv w�.6Lt.�
SIGNATURE: DATE: <3 lay L ZCr O
Accessory Structure Application Revised February 2019