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application FUEL BURNING APPLIANCE & Office use only CHIMNEY APPLICATION Permit#: KC'— — n-10X--` .Df \ Permit Fee:$ 12.,.j 0& Town oFCLcens6ury c�^_' I 742 Bay Road, Queensbury, NY 12804 Invoice:#: T P:•518-761-8256 www.queensburv.net Project Location: \® \ C g I) VTax Map ID #: a - --Ca. 11 Room of Install: 1..\ )a tUC 'cocN,A Planned Install Date: _ ' -*ZR- O 9 **ONE APPLICATION PER APPLIAN c '1-6 IE ii " , CONTACT INFORMATION: �� JUN 2 9 • • Applicant: U -rovuN oP�l��c t�``'� Name(s): �e3 l _ , ',1 s CODES audaternow mum Mailing Address, C/S/Z: G1 AAt3C) ��. Cell Phone: (c�1�C3 ) moo\-kA'Z.,-7,a1 Land Line: (,_61i ) 'l`�i j--(o�Z,.1 Email: \li ,d..(. ._l c.. rnc(1 E���iC • Primary Owner(s): Name(s): -- -- - Mailing Address, C/S/Z: Cell Phone: ( ) Land Line: _( ) Email: 0 Check if all work will be performed by homeowner only • Installer/Builder: Workers' Comp documentation must be submitt with this application Contact Name(s): C-, cc`Vj t�oL 4,`,, a04.. _ F�K� ' .1�A�\f.) Contractor Trade: VC -t-k 3tB�l� irel1va Mailing Address, C/S/Z: '-V (x \vD' � V�f e_ ��_ . _ QJ` 1 y Cell Phone:_Li---AS ) c ( \- 09 69 Land Line: _( U 1`i .) - t'-7-7- Email: Contact Person for Building & Code Compliance: ' }0t-iv3 \ 61- �_3 Cell Phone: _(ci Ig ) Not -4Z3/ Land Line: _(t i I(t3,) -7 j--((GZ4 Email: \1F07. et Q«c3nCA1-(> • (TURN OVER) Fuel Burning Appliance&Chimney Application Revised January 2020 1 1 FUEL BURNING APPLIANCE & Office Use Only ,, CHIMNEY APPLICATION Permit#: cke — rS-10 of\ �__ Permit Fee:$ 12.c Town of CLcensbury 742 Bay Road,Queensbury, NY 12804 Invoice:#: ��' P:518-761-8256 www.queensburv.net Project Location: \a sRbc Y4LT\o0 Tax Map ID #: Z7(&,-1-go `\ Room of Install: \..‘‘)%t, , 9,poiA Planned Install Date: '9 - Z9 19 **ONE APPLICATION PER APPLIAN i soi---c E CONTACT INFORMATION: 11 JUN i 9 2�L • Applicant: - " c�Y TOWN QF�IJ���its,' Name(s): �� ,j '1-,cX�\k ; , , ,l P C t� S Mailing Address, C/S/Z: 1 . (:24 c,\/1 �L S--) V� . � .rys� Cell Phone: ((59 ) 3�o\- 7J \ Land Line: ( 5 ) 1`�►�-fo(�Z! Email: \v _ CuJ .. [`�ctl E��i • Primary Owner(s): Name(s): _ Mailing Address, C/S/Z: Cell Phone:_( ) Land Line: _( ) Email: 0 Check if all work will be performed by homeowner only • Installer/Builder: Workers' Comp documentation must be submitt with this application Contact Name(s): (_, \-� _,�te boL \..,�, ,, akaJ� FN ,T � o1F-) Contractor Trade: VCr0 t13t I. k--\E'etVItOb Mailing Address, C/S/Z: -11-5 Cn '' \\OM\, '� i e_ J-R,\W.. 1 tJ- \Z2fly Cell Phone:_V-i\g ) (3( \-- ( t (a Land Line: _( \51 z�) t'-Z7-7 Email: Contact Person for Building & Code Compliance: �Q \1W-,..3 Cell Phone: _(c51( , ) 3Gt -42_3/ Land Line: ( ica) -i9 --k6Z1 Email: \tFo d. ( el i�t).3©C.Dc(> (TURN OVER) Fuel Burning Appliance&Chimney Application Revised January 2020 E- o FUEL BURNING APPLIANCE INFORMATION: TYPE OF DEVICE: Stove _Fireplace Insert ,(Fireplace Fuel Fired Equipment (Garage Only, 18" clearance per IMC 304.3) x Fireplace, factory built** (**Manufacturer's name: ,i0TE 2c\-- Model #: G _ j[o1v , i ) SOURCE OF HEAT: Wood _Coal Pellet Gas CHIMNEY INFORMATION: Masonry (require plans to be submitted): block brick stone ✓ Flue: tile 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. 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: I ;;NAst3 \)b N T RE°" _ DATE: 7-9 2.-13 Or Fuel Burning Appliance&Chimney Application Revised January 2020