AST-0344-2020 _
Office Use Only
j _ f/
ACCES5ORY'STRUCTURE/ l'f; 171)
:11 Permit#: o 3414- .4/111/°
PERM u'APPLIcaTnN
ZO2u !'
Town of Quccnsbury h Permit Fee:$
742 Bay Road,Queensbury,NY 12804
7-;}"An\J ,, .
P:518-761-8256 www.queensbury.ne-e , 3 12,l - — Invoice#.
Project Location: 3)-
Tax Map ID #: sk, 14, a- I- G27 Subdivision Name:
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CONTACT INFORMATION:': -
- _
t, •
• Applicant
Name(s): ‘,
Mailing Address, C/S/Z: c\tt -kVA Nst\--A
Cell Phone: (CIS( ) 11/4-tA Land Line: (
Email: ikuut, kiv,r1\
• Primary Owner(s):
Name(s): çiPk.C-C_QA-No.no,9-Nr\
Mailing Address, C/S/Z: Sf\A.c.tsacwk_g_aL k)t-j
Cell Phone: ( ) Land Line: (
Email:
CI Check if all work will be performed by property owner only
• Contractor(s): Workers' Comp do7entation must be submitted with this application
Contractor Name(s): NA-1 f\- CON*rtic,Z6\ --\
Contractor Trade: % \
Mailing Address, C/S/Z: \\AC\ i(' VANX-Y -
Cell Phone: ( qs6/ ) T414 Land Line: (
Email: Vu4,,A134....14\sk, .6.4Nt-l-f.A4 4 (-9•Wt•-
**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: AcTilikt..c..art—
Cell Phone: ( Land Line: (
Email:
Accessory Structure Application Revised January 2020
,
PROJECT INFORMATION:
TYPE: Commercial ?'61Residential
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: °1•''6- 1 ✓'\t )
SQUARE FOOTAGE OF STRUCTURE:
1st floor: �7h e �l 2
2"d floor: D i 5o.»5 cv� V��is, 4
Total square feet: Z a S- �. ' VI' ifr''
ADDITIONAL PROJECT INFORMATION:r _V1 1. Estimated Cost of Construction:$ v O C0
2. If Commercial project,what is the proposed use:
3. Are there any structures not shown on the plot plan? YES 11 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. 1f the work is not completed"-by the 1 year-expiration-date the permit may 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: `kY' I k-°` -'
SIGNATURE: DATE: ' '__6_,Na
Accessory Structure Application Revised January 2020