application (-----)
ACCESSORY STRUCTURE Office Use Only /
1 Permit#: - 055k-2O2'J
_ PERMIT APPLICATION
742 Bay Roa Queensbury,NY 12804 Permit Fee:$ q() U
P:518-761-8256 www.queensbury.net Invoice#: 2 � t✓
Project Location: I (+6 Lc'11 e_ `r1``-,`Y
Tax Map ID#: aoa(O. I S- I -.EK Subdivision Name:
CONTACT INFORMATION:
• Applicant:
Name(s): t c)e-,d , l4-P-PAi4,,9
Mailing Address, C/S/Z: 9\ 6C Uc,i ( 0,7 53 QJ a.4r b1 vei A 1 19,47 A) 1 0�',o."t
Cell Phone: ( S f') ci-6 , - Oa.3s-- Land Line: I )
Email: do 2e._
• Primary Owner(s):
Name(s):, psl4Je ale) :�4- I-1cy-Fv -,
Mailing Address, C/S/Z: a66 Uc, AoAss e(«r 6/cc) 41 Sa,., it+ 1:2.2cA(
Cell Phone: (5'l„V ) (. 0 - ° - 56' Land Line: ( )
Email:
❑ Check if all work will be performed by homeowner only
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): Pcs�I Q-- C.,1 Jc,1,...,
Contractor Trade: cc-i4clar 7b c r S,.„IJer—
MailingAddress, C/S/Z: (PO s.,,m73(d-e J us4- Qi-ee,Ls 5c,.--7 /t/r" lad d9
Cell Phone:, I S k ) o7_ S C Land Line: I )
Email: P.;c. t 9 5o 2o-G-t E ysi+u� . co...-1
**List all additional contractors on the back of this form
a.a ,_ .
• Architect(s)/EnKineer(s): \ --
Business Name: 1 I`.yJ 1 . _R, e e. ?V
Contact Name(s): \ I \ bQ-r u - `,
Mailing Address, C/S/Z: \ yy
f'R,.. Y1i4}-�i . �.
Cell Phone: ( ) Land Line: 6iu -,jtG_ ‘ q_r9,,'�`=��
Email: 1.------
-
Contact Person for Building& Code Compliance: P3 61'4e1--\
Cell Phone: 1. Y ) $07- _ Land Line: I )
Email: Pjc (?et .Z P f/w • .o,
Accessory Structure Application Revised February 2019
PROJECT INFORMATION:
TYPE: Commercial X Residential
WORK CLASS:
_Deck, Open Porch _Solar Panels(w/o rafter upgrades) _Carport _Cell Tower
_Shed _Pavilion, Pole Barn, Canopy _Dock _Gazebo
Detached Garage X. Boathouse (with or w/o sundeck) _3-Season Porch
Other(description:
SQUARE FOOTAGE OF STRUCTURE:
1st floor:
2"d floor: /
Total square feet: io -S
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$_ - � i 7 d O
2. If Commercial project,what is the proposed use:
3. Are there any structures not shown on the plot plan? YES (D Explain:
4. Are there any easements on the property? YES
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 thework 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:
PRI NAM : W & rn if
SIGNA • DATE: r ! 3/ao to
AccessoryStructure Application Revised February 2019