RC-0516-2018 �^ TOWN OF QUEENSBURY
a
y
� 742 Bay Road,Queensbury,NY 12804-5904 (518)761-8201
--__ Community Development - Building & Codes (518) 761-8256
CERTIFICATE OF OCCUPANCY
Permit Number: RC-0516-2018 Date Issued: Thursday, May 23, 2019
This is to certify that work requested to be done as shown by Permit Number RC-0516-2018
has been completed.
Tax Map Number: 309.9-2-1
Location: 11 Windsong DR
Owner: Homestead Village
Applicant: Homestead Village
This structure may be occupied as a: New Manufactured Home 952 s.f.
By Order of Town Board
TOWN OF QUEENSBURY
Issuance of this Certificate of Occupancy DOES NOT relieve theproperty owner 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.
e. r y TOWN OF QUEENSBURY
i' 742 Bay Road,Queensbury,
Q ury,NY 12804-5904 (518)761-8201
ti
--- _-- Community Development- Building& Codes (518) 761-8256
BUILDING PERMIT
Permit Number: RC-0516-2018
Tax Map No: 309.9-2-1
Permission is hereby granted to: Homestead Village
For property located at: 11 Windsong DR
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: Homestead Village Mobile Home $40,000.00
Owner Address: 200 Luzern RD Total Value $40,000.00
Queensbury,NY 12804
Contractor or Builder's Name/Address Electrical Inspection Agency.
Homestead Village
200 Luzern RD
Queensbury,NY 12804
Plans&Specifications
New Manufactured Home 952 s.f.
$ 190.40 PERMIT FEE PAID -THIS PERMIT EXPIRES: Wednesday,August 14,2019
(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 piration d.t;.)
Dated at the Town o Queens ; ue .Q ,��.ugust 14,2018
\SIGNED BY: for the Town of Queensbury.
Director of Building&Code Enforcement
Office Use Only
1 i MANUFACTURED HOME Permit#: C- �� � kr
APPLICATION PERMIT
Permit Fee:$ al O. fl v
mwi of Queensbury
742 Bay Road,Queensbury,NY 12804 n e $ JA
P:518-761-8256 www.queensbury.net (j
10 , itvfi : (3`7 3
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TOWN OF QUEENSBURY
BUILDING&CODES C, I
Project Location: Wa Acn N �` Tax Map ID#: 3C7.
Name of Park: \ok Vvilt, ,-- Proposed Date of Placement: SOV 2oa
r r,
CONTACT INFORMATION:
• Applicant:
Name(s): 0e.r is
Mailing Address, C/S/Z: 444.__ Q. 4 law./
Cell Phone: (S-Ij- ) s� �/a�oa Land Line: ( )
Email: ow-L.; akreN Q_ La.&
• Primary Owner(s):
Name(s): 45 �efnk LP 6 L C�
Mailing Address, C/S/Z: P.0 °fox 9 9gcfltf
Cell Phone: ( S ) gam cro Land Line: (
Email: 0,_*)L .4.,-
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• Contractor(s):
Business Name: ; -
Contact Name(s): 12,E o
Mailing Address, C/S/Z: •24," ra- 63L1.0 0z 1
Cell Phone: ( ���' ) 303 Land Line: (
Email: )4 i-IJ \h91ao,f 0 Qom
Contact Person for Building& Code Compliance: gdb AA1P444
Cell Phone: ( 6tf ) 3'3'5 Land Line: (
Email: h kde( �
•
Town of Queensbury Building&Code Enforcement Manufactured Home Application Revised May 2017
s F
MANUFACTURED HOME INFORMATION:
(INFORMATION FOUND ON THE PLATE OR STICKER LOCATED IN THE HOME):
Insignia serial#:
Name of Manufacturer: to ova.. 14 Uc- WoASLI �Vc�✓�i
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Place approval#: DD
Model or component designation (New Home Only): L, I..
Date of manufacture: •
ADDITIONAL INFORMATION:
1. Approximate Value of Home:$ l{O> U
2. Is the home NEW or a REPLACEMENT ?
3. Single-wide or Double-wide ; Size: /(f ft.x 6 i' ft.
4. Foundation support(choose one): Size Depth
Piers: Zfl- tOL
Slab:
5. Is the home being placed on a private lot? No Yes ?E (if yes,you must provide stamped engineered
drawings of the permanent foundation plan)
6. Total#of rooms(exclude bathrooms): ;#of bedrooms: 3 ;#of bathrooms: Z
7. Additional heat source? No Yes )-Choose one, if yes: gas fp ( woodstove wood fp
8. Are there any other/existing buildings on the property? No S_ Yes ; Explain:
9. What is the water source? PUBLIC PRIVATE WELL
10. Is the parcel o 7SEWER?or a PRIVATE SEPTIC system?
11. Do you need a septic permit application? No L Yes
DECLARATION:
I swear that,to the best of my knowledge and belief,the statements contained in this application,together with the
plans 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 NYS Building Code,the Zoning Ordinance and all other laws pertaining to the
proposed work shall be completed with •
1 have read and agree to the above:
PRINT NAME: cla 0t R.
SIGNATURE: G' —__ DATE: 0i,%S�<ifr
Town of Queensbury Building&Code Enforcement Manufactured Home Application Revised May 2017
`.7 3,
INSTALL NO. _ STATE OF NEW YORK fl fr:
1,1
DEPARTMENT OF STATE _i)
t ONE COMMERCE PLAZA
MT,vit. 99 WASHINGTON AVENUE AUU 2 2019
ALBANY,NY 12231
TOWN OF OUEENSBURY
INSTALLER'S WARRANTY SE4 L BUILDIRG&CODF'S
THIS SEAL REMAINS THE PROPERTY OF THE DEPARTMENT OF STATE
NEW MANUFACTURED(HUD CODE) 0 RELOCATED MANUFACTURED(HUD CODE)
A. Manufacturer's name: 1 nrf t
-7c a
B. HUD label number: \---)c- Serial number:
C. Retailer's name: 1—\\JsriC (1 r ffn
, _ ,c-kr•
D. Retailer's address: Ll L , „ \ / CA • t "/ -53 1, 1„
E. Retailer's certification#: k k
Telephone#:
F. histallees name: - V-kc
G Installer's address k or
1 /-\ t '
H. Installer's certification#: Vc_ - Telephone#:
L Date installed: 4-,-; eI r r, Municipality issuing building permit: k--1. _fi C t _4
_(city,Town,village)
J. Customer name and physical address (911)where home is installed:
‘A. '1\ ,New York.
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 9f 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 meth limitation of or substitution for,any and all other warran-
ties,express or implied,given or made by the,,Installer,whether contractually or by operation of law.
4.7c,
Printed Name of Person Signing Seal: g v ti
.----- /-
Signature of Installer or
Limite-d 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 State White Copy—Retain for Your Records Goldenrod Copy--Permitting Agency Seal—Affix-to Home
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INSPECTION WORKSHEET (MANMOD-002912-2019)
Town of Queensbury - Building and Codes - Fire Marshal
742 Bay Road - (518) 761-8256 Building (518) 761-8206 Fire Marshal
Case Number:RC-0516-2018 Case Module:Permit
Inspection Date:Thu May 23, 2019 Inspection Status:Passed
Inspector:Mark Smith Inspection Type:Manufactured Modular Final
Job Address:Parcel Number:11 Windsong DR
Queensbury, NY 12804
309.9-2-1
Contact Type Company Name Name
Granted Permission Homestead Village
Primary Owner Homestead Village
Contractor Homestead Village
Applicant Homestead Village
Checklist Item Passed Comments
Building Inspector Notes YES 5/23/19 ok to issue C/O for modular home
Model YES Commodore
Serial #YES Cr56259a
Manufacture YES Commodore homes
Date of manufacture YES 10/02/18
May 23, 2019 Page (1)
Smith, Mark (Inspector)