application ACCESSORY STRUCTURE permit#: \ — �5��
PERMIT APPLICATION Office Use Only
Town of Queensbury Permit Fee:$ /�✓
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensburv.net Invoice#: 2`'113
Project Location: 72
Tax Map ID#: Z°VA'• ko- Subdivision Name:
CONTACT INFORMATION:
• Applicant:
Name(s):_Theta_amilth
Mailing Address, C/S/Z: qq ./d abdo
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CeII Phone:_(€1g ) Z (o Land Line: _(
Email: cvr sauces j,, O "Dori
• Primary Owner(s):
Name(s): rax?1ca-:�
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line: _( )
Email:
❑ Check if all work will be performed by homeowner only,
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contact Name(s):---ropp ritrixe,
Contractor Trade: rArupiPAILYIL
Mailing Address, C/S/Z: 9c1 M LA7
Cell Phone:_(510 )QZc 196 DM Land Line: _(
Email: ECE11
**List all additional contractors on the back of this form D
SEP 2 2 2020
• Architect(s)/Engineer(s):
Business Name: TOWN OF QUEENSBURY
Contact
&CODES
Name(s):
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line: _( )
Email:
Contact Person for Building & Code Compliance: AV,P\kcV'
Cell Phone:_( _ ) Land Line: _( )
Email:
Accessory Structure Application Revised February 2019
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PROJECT INFORMATION:
TYPE: ❑ Commercial ['Residential
WORK CLASS:
L� Deck,Open Porch ❑ Solar Panels(w/o rafter upgrades) 0 Carport 0 Cell Tower
❑ Shed 0 Pavilion, Pole Barn,Canopy ❑ Dock 0 Gazebo
❑ Detached Garage 0 Boathouse(with or w/o sundeck) 0 3-Season Porch
❑ Other(description: )
SQUARE FOOTAGE OF STRUCTURE:
1st floor:
2nd floor: q e,
Total square feet:
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$ 9'5OO6 Ol7
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? 0 YES ii 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: (t cJe5 14
SIGNATURE: c ,of i7DATE: VZ
Accessory Structure Application Revised February 2019
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