BOTH-000400-2015 TOWN OF QUEENSBURY
742 Bay Road Queensbury,NY 12804-5904 (518)761-8201
i
Community Development-Building&Codes (518)761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: BOTH-000400-2015 Date Issued: Thursday, February 11, 2016
This is to certify that work requested to be done as shown by Permit Number BOTH-000400-2015
has been completed.
Tax Map Number: 316.17-1-8
Location: 11 PALMER DR
Owner: STEPHEN CHAGNON
Applicant: STEPHEN CHAGNON
This structure may be occupied as a: Gas FP
By Order of Town Board
TOWN OF QQUUEEN�JSBURY
Issuance of this Certificate of Compliance DOES NOT relieve the
property owner of the responsibility for compliance with Site Plan, LLLWWWkkk" V
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.
2015' 0
Fuel Burning Appliance & Chimney Application office Use Oniv
`�� Received
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DATE: / Tax Map ID
�EC Permit No.
TAX MAP ID: �jl l ` l��j () zU15 �1Zi -u o0%o0_ynlS
Permit Fee 50 (v,vokct kr�3
ZONE:
OWNERPHONE/E-MAIL yz�p/JAS
ADDRESS
INSTALLER/ �¢ //,eS PHONE/E-MAIL
BUILDER
CONTACT PERSON FOR BUILDING&CODE COMPLIANCE: 4r,1 l6
PHONE/E-MAIL BUILDING ADDRESS
�/ y/
ROOM OF INSTALL: PLANNED INSTALL DATE: is
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 AVAILABLE AT
TIMF OF INSPECTION
*If factory built provide manufacturer name: — 3 odel#:
Listed by: Number:
CHIMNEY INFORMATION
Masonry** (check one) _BLOCK —BRICK STONE
Flue TIE STEEL Size in inches<f'((�
Material X 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:
PRINTNAME: DATE:
SIGNATURE: Q DATE:
Town of Queensbury Building&Codes Principal Structure Application Revised September 2014