BOTH-000110-2017 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5904 (518)761-8201
Community Development-Building& Codes (518)761-8256
BUILDING PERMIT
Permit Number: BOTH-000110-2017
Tax Map No: 227.17-1-9.11
Permission is hereby granted to: Blair Gregson
For properly located at: 159 CLEVERDALERD
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: JEAN HOFFMAN Fuel Burning&Chimney $0.00
Owner Address: PO Box 222 Total Value $0.00
Clifton Park,NY 12065
Contractor or Builder's Name/Address Electrical Inspection Agency
Edward Haase
Plans&Specifications
Wood Burning Fireplace
Location:Sitting Room
$50.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Thursday,March 22,2018
(If a longer period is required,an application for an extension must be made to the code Enforcement Officer
of the Town of Queensbury before the expiration date.)
Dated at the Town o ucens [ / �We e d 22,2017
SIGNED BY: �� "/ for the Town of Queensbury.
Director of Building&Code Enforcement
FUEL BURNING APPLIANCE & Office Use Only
CHIMNEY APPLICATION Permit u: 0b>}a-lR- 2Z41L 1 �
Permit Fee:$ 50
Town of(Lueensbury
742 Bay Road,Queensbury, NY 12804 Invoice:#: 1 3
P: 518-761-8256 www.gueensburV.net
Project Location: 159 Cl everdale Road Tax Map ID #:
Room of Install: Sitting Room Planned Install Date: April 2017
**ONE APPLICATION PER APPLFBU!;-DING
� , h
AR 2 2 201
CONTACT INFORMATION: OE OUEENSBUFY
• Applicant:
& CODES
Name(s): Jean M Hoffman
Mailing Address, C/S/Z: PO Box 222 Clifton Park, NY 12065
Cell Phone: 518 ) 49568258 Land Line: ( 518- ) 371-36,83
Email: JHoffman@Lk-George.com
• Primary Owner(s):
Name(s): Jean M. Hoffman
Mailing Address, C/S/Z: PO Box 222 Clifton Park, NY 12065
Cell Phone:_( 518 ) 495-8258 Land Line: _( 518- ) - 371-8683
Email: JHoffman@LkGeorge.com
• Installer/Builder:
Business Name: Blair Gregson
Contact Name(s): Blair Gregson
Mailing Address, C/S/Z: 5185 Route 28N Newcomb, NY 12952
Cell Phone:_(
518- 582-3200 Land Line: _( 518- ) 321-6855
)
Email:
Contact Person for Building & Code Compliance: EDWARD J HAASE
Cell Phone: ( 518- ) 260-2543 Land Line:
Email: gAl L.Lc,-, Ge AoL corn
Fuel Burning Appliance & Chimney Application Revised March 2017
i
FUEL BURNING APPLIANCE INFORMATION:
TYPE OF DEVICE:
Stove Fireplace Insert XX, Fireplace
Fuel Fired Equipment (Garage Only, 18" clearance per IMC 304.3)
Fireplace, factory built**
**Manufacturer's name: Model #:
SOURCE OF HEAT:
XX Wood Coal Pellet Gas
CHIMNEY INFORMATION:
XX Masonry:
X block brick stone
_ Flue:
)X tie _steel _size, in inches
_Material*:
_double-wall _triple-wall insulated
(*Manufacturer's name: Model #: )
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.
I have read and agree to the above:
PRINT NAME:
Jean N. Hoffman
SIGNATURE: A" DATE: 3- �A —
Fuel Burning Appliance & Chimney Application Revised March 2017