application s` Office Use Only
MANUFACTURED HOME Permit#: �C,_ 0 2 0 (4? . 20 19
PERMIT APPLICATION Permit Fee: $ Z /2-0
Town ofQueens.ury
742 Bay Road,Queensbury,NY 12804 Rec Fee: $ 1Nl`P1/4"
P:518-761-8256 www.queensbury.net
Invoice#: )1\Q`D
Project Location: 67 Briwood Circle Tax Map ID #: Click or tap here to enter text.
Name of Park: Forest Park MHC Proposed Date of Placement 5/15/2019
CONTACT INFORMATION: E E fl W
11-0
• Applicant: id APR[ iI2 201;1
Name(s): Margaret Gannon �'
Mailing Address, C/S/Z: 183Pitcher Rd. Queensbury NY 12804 TG'°'' 9I�00EE JS- jPy
BUILDING& COOP"'
Cell Phone: (518) 232-7910 Land Line: (518) 7'45-7776
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
0 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 nere eu enter 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: e )_7i.
Email: forestpark@rhp-properties.com
Manufactured Home Application Revised February 2019
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 enter 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 Gan on
fit, t,ttA, I/`/1111
SIGNATURE: ( ( tap n° to enter text. DATE: Click or tap here to enter text.
Manufactured Home Application Revised February 2019