application Office Use Only
" ACCESSORY STRUCTURE .. . _-�_
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�`z'-� PERMIT APP..LICATION x 1I .
Town of Qcensbury I_ -"-." -'n�'- ,_ 1 1 l $ ' �0
742 Bay.Road,Queensbury,NY 12804. ,,-. a ,`Permit Fee 0
P:518-761-8256 www.queensburv:ne - 62jrin,oice.#: 2.-161
Project Location: 6 Z iliCJ I JP"/!!C t, . ; `•'
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Tax Map ID#; :. 3 ��• $ --�� 7"' Subdivision Name:- :.FY�rroll'�c�:: 4`' e-5:
CONTACT INFORMATION:.:
• :.Applicant:
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Name(s); ' Sh474,•-1 /a.. .A..rvCis
Mailing Address, C/S/Z: �'2 I1d? I,'i i' Qvec� e. /✓
Cell,Phone: _.(5/8 ) .9'3 7 - 3 2-o:cam:. '. Land Line: ( ': )
Email: . Si74.4...,, S "'4e hg/hccow ; Cam .. .
• Primary:Owner(s):
Name(s):. Sh4rc,., Q.'7 cry,
MailingAddress, C/S/Z: . G:2 .e /�.. r. .C 4�«Ia
f/ � � S�Vr� /1i,/
Cell Phone:_' (B/B ) 93 7 - 3 2 o.c..'. Land Line: ( )
Email: Shoo., srQcs, rihee - cam
0 Check if all work will be performed by homeowner only
• Contractor(s): Workers'Comp documentation must be submitted,with this application
Contractor Names . 1. . cyyo o tee.
U
Contractor Trade G e..-,a-c/ off € /fr ofyy>h
Mailing Address, C/S/Z: /4 attics Al p•�. �i vt :5 lam-yr /1/y
Cell Phone:. (5/6 ) 3 6/-. 4 G7 6 Land Line: : ( )'
.9 I1 ZJ cis i9�!. ' f `►/. C=ram.
Email: . . � � c/Y•�a or
**List all additional contractors on the back of this.form
• . Architect(s)/Engineer(s):
Business Name:.. 5Jr ch.Talc# •NcrS. 4 g oc r' 71'.
Contact Name(s): 566Q4...7 .Xi. ' e•s'S.
Mailing Address, C/S/Z:. .#4 3' 44.0-7'A oi ".S7`:-
i
Cell.Phone: ' (5'/i3 ) .937- .3 2 c c Land Line: ( )
Email: 5h4..cr•..7. �S#"Qe hr rrs..ca.,-7
Contact Person for Building&Code Compliance:. riptiit
Cell Phone: ( ) Land Line.:.-._ ) -o
Email.. 1 Ft- h;,1. i
SEP i , 3
I SEP 202] , �� 9
Accessory Structure Application Yf6 . . .. . 1 Revised February 2019
1 TOWN OF QUEENStisuiT . € .
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ti.
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): ,fie Gfr 7>-ze Pr.ome ,Z`,, c•
Contractor Trade: ]`ice, cr /'iosc
Mailing Address, C/S/Z: fi g/ c/y.. /j44 7 t, s7%e e,fre le,-A/,y /2 /7
Cell Phone: ( ) Land Line: ( c/g ) 2 7 — y'/a$
Email: /ecpocy/7 eV ez)/. c ory,
• Contractorisl 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:
• 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:
Accessory Structure Application Revised February 2019
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 fr"..6-azebo
Detached Garage —Boathouse(with or w/o sundeck) —3-Season Porch
Other(description:
SQUARE FOOTAGE OF STRUCTURE:
1st floor: 'S G o
2nd floor:
Total square feet: S 4O
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$ rJ' oo a —
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? YES101
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: -S17o n tip ee , dI,1 d'#5
SIGNATURE: DATE: g-/4" 2
Accessory Structure Application Revised February 2019