BOTH-000812-2016 TOWN OF QUEENSBURY
4k 742 Bay Road,Queensbury,NY 12804-5904 (518)761-8201
Community Development-Building&Codes (518)761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: BOTH-000812-2016 Date Issued: Thursday, December 15, 2016
This is to certify that work requested to be done as shown by Permit Number BOTH-000812-2016
has been completed.
Tax Map Number: 308.14-1-52
Location: 183 PITCHER RD
Owner: FOREST PARK MHC,LLC,Clifford Fortune
Applicant: Clifford Fortune
This structure may be occupied as a: Wood Stove in Kitchen
By Order of Town Board
TOWN OF QUEENSBURY
Issuance of this Certificate of Compliance DOES NOT relieve the n A
property owner of the responsibility for compliance with Site Plan, yf}'/
Variance,or other issues and conditions as a result of approvals by the Director of Building&Code EnforeWhent
Planning Board or Zoning Board of Appeals.
TOWN OF QUEENSBURY
742 Bay Road.Queensbury,NY 12804.5904 (518)761-8201
QL Community Development-Building&Codes (518)761-8256
BUILDING PERMIT
Permit Number: BOTH-000812-2016
Tax Map No: 308.14-1-52
Permission is hereby granted to: Clifford Fortune
For property located at: 183 PITCHER RD
In the Town of Queensbury,to construct or place at the above location in accordance with application together
with plot plans and other information hereto filed and approved and in compliance with the NYS Uniform
Building Codes and the Queensbury Zoning Ordinance
Type of Construction
Owner Name: Clifford Fortune Fuel Burning&Chimney $0.00
Owner Address: 15 Gregwood CBR Total Value $0.00
Queensbury,NY 12804
Contractor or Builder's Name/Address Electrical Inspection Agency
Plans&Specifications
Wood Stove in Kitchen
$50.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Saturday,December 2,2017
(If a longer period is required,an application for an extension must be made to the code Enforcement Officer
of the Town of Queensbu before the exppJ'[Janon,/date.)
Dated at the Town of ueensb {/ /Fridaa e
7 ,2016
SIGNED BY: [nM.'RI/ /•VJ 'LV for the Town of Queensbury.
Director of Building&Code Enforcement
Fuel Burning Appliance & Chimney Application office Use only
22 �a �2c c�� t�
---Received
DATE: / 6 LS ltO LS 0 l/ Ls ax Map ID g�
TAxMAP ID: 'bot . -1-`JZ O ermitNo.
ZONE:
NOV Z y 2,u.-) ermit Fee �U. GQ
TOWN OF QUEENSBURY
OWNER FForcr' r fr +n /E-MAIL
ADDRESS
INSTALLER/ PHONE/E-MAIL
BUILDER eGFFrd Forf1ne sr�769c96
CONTACT PERSON FOR BUILDING&CODE COMPLIANCE:
PHONE/E-MAIL BUILDING ADDRESS
ROOM OF INSTALL: ICJ}r�e h PLANNED INSTALL DATE:
FUEL BURNING APPLIANCE INFORMATION WOOD COAL PELLET GAS OIL NOTE: ROUGH-IN&
STOVE FINAL INSPECTION ARE
FIREPLACE INSERT REQUIRED.
FIREPLACE,FACTORY BUILT* NOTE:
MANUFACTURER'S
FIREPLACE,MASONRY
INSTALLATION MANUAL
FURNACE(GARAGE ONLY) MUST BE AVAH.ABLE AT
TIME OF INSPECTION
*If factory built provide manufacturer name: c„nmg4i,flpo-f ; Model#: 50 -S H55uio 1
Listed by: Number: fpo?a
CHIMNEY INFORMATION
Masonry** (check one) BLOCK —BRICK _STONE
Flue TIE STEEL �_Size in inches
Material DOUBLE WALL TRIPLE WALL INSULATED
** If non-masonry provide manufacturer name: ;Model#:
DECLARATION: Construction/installation must conform to NYS Fire Prevention & Building Code and/or
manufacturer requirements. The applicant or owner agrees to comply with all applicable laws, ordinances,
regulations,and all conditions that are part of these requirements and also will allow inspector's to enter premises
to perform required inspections.
I HAVE READ AND AGREE TO THE ABOVE:
PRINT NAME: CjFFn rj ro r+U n p DATE: ///.Z /6
SIGNATURE: �'� � v�2P� DATE:
Town of Queensbury Building&Codes Principal Structure Application Revised September 2014