BOTH-000366-2015 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5904 (518)761-8201
Community Development-Building&Codes (518)761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: BOTH-000366-2015 Date Issued: Monday,November 21, 2016
This is to certify that work requested to be done as shown by Permit Number BOTH-000366-2015
has been completed.
Tax Map Number: 309.7-3-2
Location: 165 SHERMAN AVE
Owner: Michael Grygas
Applicant: Michael Grygas
This structure may be occupied as a: Coal/Pellet stove
Vermont Castings,Resolute By Order of Town Board
TOWN OF QUEENSBBURY
Issuance of this Certificate of Compliance DOES NOT relieve the
property owner of the responsibility for compliance with Site Plan,
Variance,or other issues and conditions as a result of approvals by the Director of Building&Code Enforcement
Planning Board or Zoning Board of Appeals.
TOWN OF QUEENSBURY
ow 742 Bay Road,Queensbury,NY 12804-5904 (518)761-8201
Community Development-Building&Codes (518)761-8256
BUILDING PERMIT
Permit Number: BOTH-000366-2015
Tax Map No: 309.7-3-2
Permission is hereby granted to: Michael Grygas
For property located at: 165 SHERMAN AVE
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: Michael Grygas Fuel Burning&Chimney $0.00
Owner Address: 165 SHERMAN AVE Total Value $0.00
Queensbury,NY 12804
Contractor or Builder's Name/Address Electrical Inspection Agency
Delong Division
Plans&Specifications
Coal/Pellet stove
Vermont Castings,Resolute
$50.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Sunday,November 13.2016
(If a longer period is required,an application for an extension must be made to the code Enforcement Officer
of the Town of Queensbury before the expiration date.)
Dated at the Town ofQeeEtn n AThur r 19,2015
SIGNED BY: `( (.,M►_` for the Town of Queensbury.
Director of Building&Code Enforcement
BOTH 000366-2015
Fuel Burning Appliance & Chimney,Application _ Mike Grygas
g! e/5' / 165 Sherman Avenue
4
DATE: '/.tib"' Stove - coal, pellet
TAX MAP ID: _ NOV 19 20ta a it No. o r F o0031�6_ S
L . Pe it Fee
ZONE: TOWN OF QUEENSBUR
BUILDING & CODES �✓Or' ('—
OWNER �2 PHONE/E-MAIL 'V7 Of',I�j/I/
ADDRESS IVY
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INSTALLER/ - r PHONE/E-MAIL DSlon�'
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BUILDER �G/O/� /✓15iWr Kris U£� , SIS -I -//1W //{��.C�d�7
CONTACT PERSON FOR BUILDING&CODE COMPLIANCE: l
PHONE/E-MAIL BUILDING ADDRESS $�
ROOM OF INSTALL: 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:
FIREPLACE,MASONRY MANUFACTURER'S
INSTALLATION MANUAL
FURNACE(GARAGE ONLY) MUST BE AVAILABLE AT
TIME OF INSPECTION
*If factory built provide manufacturer name: P9W,d ; Model#:
Listed by: Number:
CHIMNEY INFORMATION
Masonry** (check one) BLOCK —BRICK _STONE
Flue TIE STEEL Size in inches
Material _DOUBLE WALL ,X TRIPLE WALL X INSULATED
** If non-masonry provide manufacturer name: ; Model#: 60
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: /
PRINTNAME: C �f DATE: / l r
SIGNATURE: DATE:
Town of Queensbury Building&Codes Principal Structure Application Revised September 2014