application Office Use Only
MANUFACTURED HOME Permit#: eC• ^p 2-05- 2-0 1
PERMIT APPLICATION Permit Fee: $ � 2�
Town of Queensriury
742 Bay Road,Queensbury,NY 12804 Rec Fee:$ rjtPc
P:518-761-8256 www.queensbury.net
Invoice#: 1 _
Project Location: 95 Briwood Circle Tax Map ID #: or tap here to enter text.
Name of Park: Forest Park MHC Proposed Date of Placement 5/15/2019
CONTACT INFORMATION:
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• Applicant: , I
Name(s): Margaret Gannon i APR 12 2019 %�
Mailing Address, C/S/Z: 183 Pitcher Rd. Queensbury NY 12804 irovvT4 of iTE . ; :
Cell Phone: (518) 232-7910 Land Line: (518) 745-7776 BUIL.a;NG«` `:'3"
Email: forestpark@rhp-properties.com
• Primary Owner(s):
Name(s): Forest Park MHC LLC
Mailing Address, C/S/Z: 183 Pitcher Rd. Queensbury NY 12804
Cell Phone: same Land Line: same
Email: same
Check if all work will be performed by homeowner only
• Contractor(s):
Contact Name(s): Dan Hunt/Hunt's Home Services LLC
Contractor Trade: Click or tap here to otter text.
Mailing Address, C/S/Z: 36 Brickoven Rd. Queensbury NY 12804
Cell Phone: (518) 361-2931 Land Line: N/A
Email: dirtywhiteboy970@yahoo.com
**List all additional contractors on the back of this form
Contact Person for Building & Code Compliance: Margaret Gannon
Cell Phone: (518) 232-7910 Land Line: 06}1. 5 111 '
Email: forestpark@rhp-properties.com
Manufactured Home Application Revised February 2019
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MANUFACTURED HOME INFORMATION:
(INFORMATION FOUND ON THE PLATE OR STICKER LOCATED IN THE HOME):
Insignia serial #: Click or tap here to enter text.
Name of Manufacturer: Champion
Place approval#: Click or tap here to entfi`text.
Model or component designation (New Home Only) 122-L-26612
Date of manufacture: 2019
ADDITIONAL INFORMATION:
1. Approximate Value of Home: $50,000
2. Is the home NEW X or a REPLACEMENT ❑?
3. Single-wide X or Double-wide ❑; Size: _16__ft.X_76_ft.
4. Foundation support(choose one): Size Depth
❑ Piers: 2' 4'
❑ Slab:
5. Is the home being placed on a private lot? No_X Yes (if yes,you must provide stamped engineered
drawings of the permanent foundation plan)
6. Total#of rooms(exclude bathrooms):_5_;#of bedrooms:_3 #of bathrooms:_2__
7. Additional heat source? No X Yes❑ Choose one, if yes: gas fp ❑ woodstove ❑ wood fp ❑
8. Are there any other/existing buildings on the property? NoX Yes ❑; Explain: Click or tap here to enter text.
9. What is the water source? PUBLIC X PRIVATE WELL ❑
10. Is the parcel on SEWER or a PRIVATE SEPTIC system? Septic
11. Do you need a septic permit application? No X 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: Margaret Gannon
SIGNATURE: Lick r taps rlere to enter text DATE: ^ lhc',c or tap here to enter text.
Manufactured Home Application Revised February 2019