FMP-0419-2018
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: FMP-0419-2018Date Issued: Monday, January 7, 2019
This is to certify that work requested to be done as shown by Permit Number
FMP-0419-2018
has been completed.
240.6-1-18
Tax Map Number:
21 HANNEFORD RD
Location:
John Shafer
Owner:
John Shafer
Applicant:
This structure may be occupied as a: Wood Stove installed in family room
By Order of Town Board
TOWN OF QUEENSBURY
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.
s-v TOWN OF QUEENSBURY
f-�
742 Bay Road,Queensbury,NY 12804-5904 (518)761-8201
- - Community Development- Building& Codes (518) 761-8256
BUILDING PERMIT
Permit Number: FMP-0419-2018
Tax Map No: 240.6-1-18
Permission is hereby granted to: The Cozy Cabin Stove&Fireplace Shop
For property located at: 21 HANNEFORD 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: John Shafer Solid Fuel $0.00
Owner Address: P.O.Box 225 Total Value $0.00
Cleverdale,NY 12820
Contractor or Builder's Name/Address Electrical Inspection Agency
The Cozy Cabin Stove&Fireplace Shop
217 NY-28
Warrensburg,NY 12885
Plans&Specifications
Wood Stove installed in family room
$ 250.00 PERMIT FEE PAID -THIS PERMIT EXPIRES: Wednesday, July 3,2019
(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 uee ury; ue 2018
SIGNED BY: for the Town of Queensbury.
Director of Building&Code Enforcement
- t r
FUEL BURNING APPLIANCE & office use only
HIIV��Ey T(O Permit#:
��,,,f' ll��pp�� Permit Fee:$ �50.-� 00
Town of Queensbury V IV 29 ��
742 Bay Road,QueerAury, NY���Q' 2804 Invoice:#: ( ,
P:518-761-8256 www. ueenskbur 7AWVH OF QUEE SBURV
GILDING&CODES
Project Location: Tax Map
Room of Install: J Planned Install Date:
**ONE APPLICATION PER APPLIANCE**
CONTACT INFORMATION:
4 Applicant:
Name(s):
Mailing Address, C/S/Z:
Cell Phone: ( ,S%0 47L La Line:
Email: .�q'4y
a Primary Owner(s):
Name(s): 13�
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line: _( )
Email:
Installer/
Business Name: t! /?
Contact Name(s): d yrJtJ
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line: _( )
Email:
Contact Person for Building & Code Compliance: 5;?me a-!;- 1��i7j f
Cell Phone: _( ) Land Line: _( )
Email:
Fuel Burning Appliance&Chimney Application Revised March 2017
Y
FUEL BURNING APPLIANCE INFORMATION:
TYPE OF DEVICE:
Stove _Fireplace Insert _Fireplace
Fuel Fired Equipment(Garage Only, 18" clearance per IMC 304.3)
_Fireplace,factory built**
**Manufacturer's name: , � /���. Model#: /^ Y-a 71
SOURCE OF HEAT:
Wood _Coal _Pellet _Gas
CHIMNEY INFORMATION: 4,014 6)
_Masonry:
block brick _stone
. oew,ee
Flue. /+
t/r tie _steel size, in inches / j JG�
*: - e. /act
_Material ��� � !'H
double-wall!5� triple-wall7,V tee
(*Manufacturer's name: GModel #:
ADDITIONAL INFORMATION:
1. Two inspections are required. A rough-in inspection, prior to installation and a final inspection, after
installation.
2. Manufacturer's installation manual must be available at the time of inspection.
3. Masonry fireplaces&chimneys require plans to be submitted.
4. Twenty-four(24) hour notification is required for inspections.
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 the inspector to enter the premises to perform the
required inspections.
have read and agree to the above:
PRINT NAME:
SIGNATURE: DATE:
Fuel Burning Appliance&Chimney Application Revised March 2017