application :-`-. Office.Use Only
`',- ACCESSORY STRUCTURE
may` Permit#: T' 0 tot.�j 20N)
PERMIT APPLICATION Town ofQucensbury Permit Fee:$ I2,t_
742:Bay_Road,Queensbury,NY 12804
P:518-761-8256 www.queensburv.net Invoice#:
Project Location: 2. P\n es9- V. ff
Tax Map ID #: 5110° ).0104- 1.--1, ubdivision Name: VOA
CONTACT INFORMATION:
• A licant: �1 (�
Name(s): ,0� '" V\Colco,A\g C/S/Z: - 0 �p E C4�,.�e n u 1� vo oMailin Address, PI � 1 � �
Cell Phone: ( 9 ) !I%-" -1jb Land Line: ( )
Email:.
• Prima r Owne_rn( ):
Name(s): i��1 j 1\ ti114 .4�\ ,�f `�
Mailing.Address, C/S/Z: _ isi f tb J� SJ`? ��is� ' sA3wr ' 1 V 1 i),g b
Cell.Phone: ( ; )'7 q -- CP 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):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: ( )
Email: fp c : [i `\F.2 -- �1
**List all additional contractors on the back of this form —v=.-- l"
OCT 30 2020
• Architect(s)/Engineer(s): r_ —
Business Name: TOWN OF ni UFENS1 UR't
Contact Name(s): BUILDING&CODES
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: ( )
Email:
Contact Person for Building& Cock Cq pliance: Ow I` TT'k
Cell Phone: ON ) 36 I- '64! 4T 1 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 _Gazebo
Detached Garage —Boathouse(with or w/o sundeck) _3-Season Porch
Other(description: )
SQUARE FOOTAGE OF STRUCTURE: _
1st floor: --(k_ )bt '1. , rif d'c c,'\
2"d floor:
Total square feet: 5OO sT,
ADDITIONAL PROJECT INFORMATION:
10 1. Estimated Cost of Construction:$ -00
2. If Commercial project,what is the proposed use:
3. Are there any structures not shown on the plot plan? YES a Explain: -
4. Are there any easements on the property? YES. ille—v
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: .5\O61 n P\ . C �) Ot I
SIGNATURE: ' c7� 1 Y 1 N , Ot)Ot DATE: 1 O I a cI I Z f�
Accessory Structure Application Revised February 2019