RC-000589-2016 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5904 (518)761-8201
Community Development-Building&Codes (518)761-8256
CERTIFICATE OF OCCUPANCY
Permit Number: RC-000589-2016 Date Issued: Wednesday, September 28, 2016
This is to certify that work requested to be done as shown by Permit Number RC-000589-2016
has been completed.
Tax Map Number: 308.14-1-52
Location: 183 PITCHER RD
Owner: FOREST PARK MHC,LLC
Applicant: FOREST PARK MHC,LLC
This structure may be occupied as a:Mobile Home in Park(mobile home is
repo) By Order of Town Board
Forest Park MHP: 15 Gregwood Circle TOWN OF QUEENSSBBUR�YJ
Issuance of this Certificate of Occupancy DOES NOT relieve the r
property owner of the responsibility for compliance with Site Plan, ������///LLL��W✓✓lNN� 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.
TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5904 (518)761-8201
OL Community Development-Building&Codes (518)761-8256
BUILDING PERMIT
Permit Number: RC-000589-2016
Tax Map No: 308.14-1-52
Permission is hereby granted to: Combs Trucking
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: FOREST PARK MHC,LLC Mobile Home $30,000.00
Owner Address: 183 Pitcher RD Total Value $30,000.00
Queensbury,NY 12804
Contractor or Builder's Name/Address Electrical Inspection Agency
Combs Trucking
96 VAN DUSEN RD
Queensbury,NY 12804
Plans&Specifications
Mobile Home in Park(mobile home is repo)
Forest Park MHP: 15 Gregwood Circle
$115.20 PERMIT FEE PAID-THIS PERMIT EXPIRES: Friday,September 8,2017
(If a longer period is required,an application for an extension must be made to the code Enforcement Officer
of the Town of Queensbury before the expiration date.)
Dated at the Town of ury; IFrida , e tuber ,2016
SIGNED BY: /Q for the Town of Queensbury.
Director of Building&Code Enforcement
*
MOBILE HOME APPLICATION Office Use Only
ry Received
DATE: _ a I���LD Tax Map ID 30'R,
Permit No. C GaG
TAX MAP ID Q EPermit Fee �l( 5 ZQ
PROPEFrry LOCATION: 5�1"ephlODLI C.iYUe 1 Sp� /
NAME OF MOBILE HOME PARIC Mrunt�P(uri< rnN-C i✓
PROPOSED DATE OF PLAQEMENT7 _ IcJ 1 1 LO
APPLICAO
NT. fOI�7Pn,J'`�y��(vM,1L��,,I�1171. WNER
ADDRESS I1 ADDRESS. ^
PHONE l'/115)�-1 ��I,� PHONE
NAME OF INSTALLER.OR MOBILE
� 1�HQ�M'E,DEALER �(� COMPS True1<,n-1
VIA.
ADDRESS: A Le r(r�,l,l �(X
a�Ld
PHONE (�1� nC"�I _75g ..q �� ��. �[,{
CONTACT RERSONfOR BUILDING&-CODFS COMPLIANCE:�� I�.v yr y� y 1 _PHONE.
COMPLETE INFORMATION BELOW.FOUND 014 A'PLATE".OR'"STICKER"WHICHIS AFFIXED TO THE MOBILE HOME
Insignia serial number 1032 Pt
Name of Manufacturer movnpiokl
Place Approval Number
Model or Component pe$gn.ation (New home only)
Date of Manufacture: t7
MOBILE HOME INFORMATION ZONING INFORM"ON
Approximate Value of Home $ Zoning
New Home or Replacement Size of property
Size of MobilaRome _Ux—n,by. (00 ft. E dstirrg buildings I
Sigglewfde&Doublewfde S Accessory buildings
Number of rooms.(exclude bath) Storage buildings
Number of13edrgoms Detached Garage
Number ofBathrooms pgachedGarage j _12
Gas Fireplace;wbodstoveor4VbodF¢apjggg WDO,InSetbacks. Frontyard: ft,
LA Rear yard:,
Side yard: _ft.
Foundatlop Suppoit Slid Depth wale r Supply }IJet;
Piers Munteipal:
Runners
SIaTi Septic Perrrlit Required? -Yes ✓Nd
Town of Queensbu Building 1
ry 8 8s Gbdes Mobile Home Application July 2014
Procedure for placing and occupying a mobile home or modular home:
1. Application is submitted and review: 2 copies of plot plan and layout must accompany application along with
septic application(iE needed)and fee.
2. Permit is issued— Permit card is placed on property
3. Footing forms are inspected before pouring concrete: Home is placed on foundation orpiers.
4. Arrange for electrical inspection—see"Certified Electrical form" on Town website
6. Septic Inspection, if needed
6. Final electrical inspection
7. Stairs &.platform covering door width and door swing with handrails on both sides of platform and stairs are
required for all'exterior doors.
8. Final inspection by Building &Codes Department
9. All mobile f manufactured housing must be anchored to the ground upon which they are site per
manufacturer requirements.
10. Installer Warranty seal must be provided at the time of Certificate of Occupancy
11. If anchoring is not possible due to weather conditions or any other item, a Temporary Certificate of Occupancy
will be issued; Fee.-$1:0; Deposit$100.00 (refunded when all items are complete)
McLARA7lom I swear that to the best of my knowledge and belief the statements contained in this application,
together with the plant and specifications submitted, are a true and complete statement of all proposed work to be
done on the described premises and that all.provisions of the Building Code,the Zoning Ordinance,-and all other laws
pertaining to the proposed work shall be completed.with,whether specified or not,and that such work is authorized by
the owner. Installer Warranty will be provided at time of Certificate of Occupancy.
Print Name: (t Q Q I P Llyl A 0 0 Date: RJany 11(O
�Onwnner, ent,Contractor /
Signature: UV IA AAE Date:60
�Ic�J�III
Special Conditions of Permit:
By: Cade Enforcement Officer
2
Town of Queensbury Building 4 Codes Mobile.Home Application July 2014
r, -y
INSTALL NO. STATE OF NEW YORK
IWO DEPARTMENT OF STATE hC- ppp58q - 7-b
ONE COMMERCE PLAZA
99 WASHINGTON AVENUE
ALBANY,NY 12231
INSTALLER'S WARRANTY SEAL
THIS SEAL REMAINS THE PROPERTY OF THE DEPARTMENT OF STATE
❑ NEW MANUFACTURED(HUD CODE) ® RELOCATED MANUFACTURED(HUD CODE)
A. Manufacturer's name: CAW
B. HUDlabelnumber. fS //6��3/ Serial number: a9-L-,`0>//-A61p
C. Retailer's name:
i
D. Retailer's address: l JZ r✓Arm ,ASL
E. Retailer's certification#: Telephone#:
r
F. Installer's name: /YlOi—ale.\\X "A'as
O. Installer's address: 9/ t�✓15X.+ 0
1[4
H. Installer's certification#. / Z/rAOrZ91 Telephone#: S-1k 79dY273f'
I. Date installed: <3��/G Municipality issuing building permit:
(CityCTpwlf dlage)
J. Customer name and physical address (911)where home is installed: J5RI •4-,4
/S Gnlb[.�ooJ (A&.F Lv,4&ac 7 k- New York. .zrb
By attaching this SEAL to this manufactured home,the undersigned Installer of this manufactured home warrants as follows:
1. That the installation of this manufactured home meets the standards of the New York State Uniform Fire Prevention and Building
Code.
2. That the Installer is certified as an installer by the New York State Department of State.
The foregoing warranties are in addition to and not in derogation of all other rights and privileges which the consumer may have under any
other law or instrument.The foregoing warranties are in addition to,and not in limitation of or substitution for,any and all other warran-
ties,express or implied,given or made by the Installer,w ther contractually or by operation of law.
Printed Name of Person Signing Seal:
Signature of Installer or
Limited Installer: /
If you have a problem with your home,you should first contact your installer or retailer.If the problem is not resolved by the Installer or
Retailer you can contact the Department of State at(518)474-4073.
DOS-1680(Rev.03/09)
Yellow Copy—Department of Stale White Copy—Retain for Your Records Goldenrod Copy—Permitting Agency Seal—Affix to Home