application Office Use Only
MANUFACTURED HOME Permit#: R C— Or't(�- ZO( 7
PERMIT APPLICATION
Permit Fee: $ � � j ZC�
Token of tbeensbury �(]
742 Bay Road,Queensbury, NY 12804 D E C L f V IEC i e' $ N1/4
P:518-761-8256 www.queensburv.net
MAR 26 2019 lr'vi 13 2-7
TOWNILOFA NG&CODES ENSBURY
Project Location: 1 YlOOd'MAC P0A1 04)9 Tax Map ID #: 3O ,
Pro osed Date of Placement: 51111 C'
Name of Park: �ul��s� PCUrK (�')� Cl p
CONTACT INFORMATION:
• Applicant:
Name(s): MCI- J(L(Ck GCLVIY100
Mailing Address, C/S/Z: I g3 P4610( RA- (W e eirlskJ1,crL Ny 12 -1
Cell Phone: (51 8 ) a3a 1Q i b Land Line: (51 g ) 145- 1-17 Co
Email: ore.skpark rhp —pirapey+i&s• earn •
• Primary Owner(s):
Name(s): IoreS E Ala Y'Y1 NC LLCC'
Mailing Address, C/S/Z: IQ3_PiAeci . .0 SN- wwaq _._. _ ,-
Cell Phone: ( ) Land Line: ( ) -%-Q
Email:
❑ Check if all work will be performed by homeowner only
• Contractor(s):
Contact Name(s): 14IA-VIA 1-6vne C.S)erf Lk LLC
Contractor Trade:
Mailing Address, C/S/Z: Brici_OVtv1 Q(t CJ9b1 i!a8o4
Cell Phone: (5-I g ) 3(01- (9g3 I Land Line: ( ) t\)1 A
Email: C1Irh9tAi-i-600.1'10° tyaloo .c_�v►�
**List all additional contractors on the back of this form
Contact Person for Building & Code Compliance: CL9 o- _ 6 A.V✓l
Cell Pho e: (Mg ) " a30-`7q ID Land Line: (
Email: -0Q.S- pCA.riC e rho-pmixex+,-e. 3
Manufactured Home Application Revised February 2019
MANUFACTURED HOME INFORMATION:
(INFORMATION FOUND ON THE PLATE OR STICKER LOCATED IN THE HOME):
Insignia serial #:
Name of Manufacturer: C;f1ttiji,WIC)1/1
Place approval #:
Model or component designation (New Home Only): 121-
Z-
Date of manufacture: L)
ADDITIONAL INFORMATION:
1. Approximate Value of Home: $ ,5bii coo
2. Is the home NEW ✓ or a REPLACEMENT ?
3. Single-wide or Double-wide ; Size: I( o ft.X /67 ft.
4. Foundation support (choose one): Size Depth
,c) I..
Piers:
Slab:5. Is the home being placed on a private lot? No v/ Yes (if yes,you must provide stamped engineered
drawings of the permanent foundation plan)
6. Total#of rooms(exclude bathrooms): ; #of bedrooms: ;#of bathrooms:
7. Additional heat source? 7 . '��_ _ Choose-?i E;Ss yes:-Sfisfp woodstove -wood fp i
S. Are there any other/existing buildings on the property? No Yes ; Explain:
9. What is the water source? PUBLIC PRIVATE WELL
10. Is the parcel on SEWER or a PRIVATE SEPTIC system? aLptal..
11. Do you need a septic permit application? No V 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
I have read and agree to the above:
PRINT NAME: )7Y)artca,irtf lGtlrZ �'1�%
SIGNATURE. Trifth,P .„,,. 1l'tif/ti�l DATE:
1
Manufactured Home Application Revised February 2019