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Application Office Use Only ACCESSORY STRUCTURE Permit#: � �21 PERMIT APPLICATION Permit Fee: 5 i 742 Bay Road,Queensbury,NY 12804 Invoice#: Z}(( P:518-761-8256 www.gueensbury.net Flood Zone? Y ( N ) Reviewed Bv: Project Location: 13 /� K� 1 I L I `J " �j �� ON Tax Map ID#: 5 Z 3 1 00 �J'fU O �j,1'� . 1� _7-3` Subdivision Name: N PROJECT INFORMATION: TYPE: ,IK Residential ❑ Commercial, Proposed Use: crni o/ i mc. ❑ Boathouse(with or w/o sundeck) ❑ Canopy ❑ Carport ❑ Cell Tower ADeck I I Detached Garage f�3Qn c t.i I nark _I GA7phn ❑ Pnw jinn — Pnla Rnm ❑ Porch ❑ Ramp ❑ Shed (<300 s.f.) ❑ Solar Panels(w/o rafter upgrades) ❑ 3-Season Porch ❑ Qtbo 'i SQUARE FOOTAGE OF STRUCTURE: l' r LI �l JUNJUN O 9 2- 021� 1st floor: 5 I Z 5J f{ OF 2n°floor: N Qr TO p NG & COD SRY ,I Total square feet: I Z N Brief description of scope of project: �J 0ddiH � Ott(/Y— h q baa of l� oufL . itwiIl be M� ouvt fyom tu house and Klf Ian �"U9 h w � � h staff rf o f the b(��iK o f f K (09 firm hou�� V9 down ant- yard. Accessory Strstture AoVITaj,on uewwc January 2021 AnnITinryyAL pvn��r r �n¢nonnnTlnni. 1. Estimated Cost of Construction:$ I O 0 d 2. Are there any structures not shown on the plot-!an? DYES XNO Explain: 3. Are there any easements on the property? ❑ YES OSNO DECLARATION: 1. I acknowledge that no construction shall be commenced prior to the issuance of a valid permit and will be completed within a 12 month period.Any changes to the approved plans prior to/during construction will require the submittal of amended plans, additional reviews and re-approval. 2. If,for any reason,the building permit application is withdrawn,30%of the fee is retained by the Town of Queensbury.After 1 year from the initial application date, 100%of the fee is retained. 3. If the work is not completed by the 1 year expiration date the permit may be renewed, subject to fees and department approval. 4. 1 certify that the application, plans and supporting materials are a true and a 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. 5. 1 acknowledge that prior to occupying the facilities proposed I, or my agents, will obtain a certificate of occupancy. 6. 1 also understand that[Ave 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. 1 have rood and agree tc the above: PRINT NAME: JOS h VM I I W SIGNATURE: DATE: I Accessory Structure Appika[ion Revises January 2021 A f AIUTAf•T 1111GAD11A 11 TIA 111. I'll CA CC nDIhlT 1 C/`IDI V nO NnC DI CA CC IAI!`I I lhC AKI C•AAll VVIY I/lV 1 11\I VI\IY1I111V1\• r LL/"1JL r 1\IIY 1 LLVIULI VI\ I I 1 L, ( LL/YJL IIYI_LV VL f11Y LIYI/"11L • Applicant: /� /� 9 /� I//� Name(s):� ) J h V 1 OU�lI I A NI Q m Mailing A dress, C/S/Zh 1 l CellMai Phone: �JI� N� IIyR K- � NL n�L� 1Ray 1-e11 corn • Primary Owl nerr(s): //'�� pp ''nn Name(s): MOO I'� 0111VOr Mailing Address, C/s/Z: 2b K-1 1 6f lit Qr, a nYi a tj Ny I Z H Cell Phone: 51� yOj lyq Land Line: Email: 0 j0ShUa, MAI � I � r9 ��h © US L.IIc6n 11 QII WVIn W111 NC FJCI IVIIIICu Yy F!1 VF/CI ly VWIICI aJ iIIZ • Contractor(s): (List all additional contractors on the back of this form) Contractor Name(s): Contractor Trade: Mailing Address, C/s/Z: Cell Phone: Land Line: Email: "Workers' Comp documentation must be submitted with this application" Arch Itecticl%Fnoi nooricl• Business Name: Contact Name(s): Mailing Address, C/5/Z: Cell Phone: Land Line: Email: fnntarf Parcnn for any questions regarriina this nrniart• :J OJ V IJW{ I IG Vv/ Q OY _o_._. o _..._ r. -,___. Cell Phone: �jnl�/-�Zl i II I/_'7q ljl VLi i I/i Land Line: f (OW Email: i OShv �'� ,1PalIlAtgtVrp UJ , t1 . Nttersory gym:It lr^Noel C£.a4 I<cv6Bp January ID2.