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FUEL BURNING APPLIANCE &Office Use Only CHIMNEY APPLICATION __|,ECE! Town of Queensbury | 742 Bay Road,Queensbury,NY 12804 |P:518-761-8256 www.queensbury.net | 1,TO Project Location:185 sunnyside va = ¥ Room of Install:Basement Jrivig SOM Planned Install Date:__||do **ONE APPLICATION PER APPLIANCE ** CONTACT INFORMATIOI ©Applicant: Name(s):_Zachacy Nile Mailing Address,C/S/2:__185 sunnyside cd Que.asbory NOY 19804 Cell Phone:(K\R_)BL\-5063 *Land Line:_(4) Email:20 ¢Primary Owner(s): Name(s): Mailing Address,C/S, Cell Phone:_()Land Line:_() Email: yf Check if all work will be performed by homeowner only «Installer/Builder:Workers’Comp documentation must be submitted with this application Contact Name(s):Zachary Allen Contractor Trade: Mailing Address,C/S/Z: Cell Phone:(SIG)Bl -50G5 land Line:_() Email: Contact Person for Building &Code Compliance:_Same _as_above Cell Phone:_()Land Line:_(__)Email: Fuel Burning Appliance &Chimney Application Revised February 2019 FUEL BURNING APPLIANCE INFORMATION: TYPE OF DEVICE: Stove __Fireplace Insert __Fireplace ___Fuel Fired Equipment (Garage Only,18”clearance per IMC 304.3) __Fireplace,factory built** (**Manufacturer’s name:Enclonds shuenorks model:D-CRIQO _) SOURCE OF HEAT: ___Wood __Coal >»Pellet Gas CHIMNEY INFORMATION: ___Masonry (require plans to be submitted): ___block ___brick __stone X_Flue: __tile K steel 3 size,in inches __Material*:1 double-wall —__triple-wall_¢insulated (*Manufacturer’s name:__Pellet ven Model #:SPVL-KWA _) 1.Two inspections are required.A rough-in inspection,prior to installation and a final inspection,after installation. Manufacturer's installation manual must be available at the time of inspection. Masonry fireplaces &chimneys require plans to be submitted ‘Twenty-four (24)hour notification is required for inspections. Workers’Comp insurance information is required with this application. yen 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:en SIGNATURE:DATE:fs|20.a) Fuel Burning Appliance &Chimney Application Revised February 2019,