application FUEL BURNING APPLIANCE & Office Use Only
CHIMNEY APPLICATION Permit#: P1k) '
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Permit Fee:$
town of(jyeensbuny
742 Bay Road, Queensbury, NY 12804 Invoice*: tb491
P: 518-761-8256 www.queensbury.net
Project Location:/3/ TR/E Z4N ,( v EENS BVV'/ Tax Map ID #: 3 0 6 , I 'I
Room of Install: IL/ V//YG i4o Planned Install Date:
**ONE APPLICATION PER APPLIANCi [ECEOVE0
APR 10 2019
CONTACT INFORMATION:
TOWN OF QUEENSBURY
• Applicant: jj BUILDING&CODES
Name(s): c:�?/ '41- /D c G
Mailing Address, C/S/Z: %3 P€— /E . l/✓E')Q ve€tiSBUk'Y, NY /28 04
Cell Phone: (864 ) 3‘.3 -/a2&Z Land Line: (6 /8 ) 7 / / 08 3
Email: e i--)-, / h q -it,S` 9,2 2 62 j yr�c ! / ® v�'I
• Primary Owner(s):
Name(s): .mac/V r=9 LD 4/VP DE1r,4 n /
Mailing Address, C/S/Z: /3 ! TR/E1 . ./EE7V 8t'RY, N Y /28e -
Cell Phone: _(& '/ ) 36.3 —/Z 6 .Z Land Line: ( S/fl ) 7 / C 0 83
Email: K /1"i , 7 L59,22C gi.-re i/ . C� ✓�
LS Check if all work will be performed by homeowner only
• Installer/Builder: Workers' Comp documentation must be submitted with this application
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _(
Email:
Contact Person for Building & Code Compliance: J.,-Po WALD J6 NG-
Cell Phone: ( 894) 363 -- 1.2 62 Land Line: (L%8 ) -74/ Co 093
Email: d+-»k i rq 439 .26\ c:`r`/ 6,77
Fuel Burning Appliance&Chimney Application Revised February 2019
FUEL BURNING APPLIANCE INFORMATION:
TYPE OF DEVICE:
yStove Fireplace Insert Fireplace
Fuel Fired Equipment (Garage Only, 18" clearance per IMC 304.3)
Fireplace, factory built**
(**Manufacturer's name: //,/6 KS Model #:50 save, / 3 )
SOURCE OF HEAT:
X Wood Coal Pellet Gas
CHIMNEY INFORMATION:
Masonry (require plans to be submitted):
block brick stone
Flue:
tile X steel 6 size, in inches
Material*:
)( double-wall triple-wall insulated
(*Manufacturer's name: S U f E/Z En/7- Model #: ,TS C 6 S-43
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.
5. Workers' Comp insurance information is required with this application.
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: :DO/VA-Lb Al. k A G
SIGNATURE: '/ �l ' DATE: 0//2
Fuel Burning Appliance&Chimney Application Revised February 2019