application Office Use Only
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r- MANUFACTURED HOME Permit#: QG. - 0 2134 .
PERMIT APPLICATION Permit Fee:$ 2.2S 2O
Town of Queensbury
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net Rec Fee:$ '\--
Invoice#: V100
Project Location: 45 Briwood Circle Tax Map ID #: or tap here to =:ale:
Name of Park: Forest Park MHC Proposed Date of Placement 5/15/2019
CONTACT INFORMATION: " 6 L °
e
• Applicant: I 1 APR 12 2019
Name(s): Margaret Gannon ! —
TOWN OF QUEENSB RY
Mailing Address, C/S/Z: 18:3 Pitcher Rd. Queensbury NY 12804 BUILDING&CODES
Cell Phone: (518) 232-7910 Land Line: (518) 745-7776
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
[� Check if all work will be performed by homeowner only
• Contractor(s):
Contact Name(s): Dan Hunt/Hunt's Home Services LLC
Contractor Trade: : :;, . a
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: ( )
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 Gannon
SIGNATURE: 4; r '^ _ '.._DATE: 11,1 II 1aa here to enter text.
Manufactured Home Application Revised February 2019