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FUEL BURNING APPLIANCE &Office Use Only CHIMNEY APPLICATION permit a:FIM\P-0020-2020 permit fee:$__'2>~ Town of Queensbury 742 Bay Road,Queensbury,NY 12804 tnvoicen:25% P:518-761-8256 www.queensbury.net gearProjectLocation:7/7 “MorShc Ho 29 COR Map ID #: Room of Install:Z/vr+6 Zea Planned Install Date:__“ed ~><er 2020 **ONE APPLICATION PER APPLIANCE** CONTACT INFORMATIOI ©Applicant: Name(s):(¢teateg MO eee Mailing Address,C/S/Z:___77>_wr Ane Kone Pigery nv aeoy Cell Phone:_(S7P_)7*Y-E872 Land Line:_() Email:Dirtrete @ goiaev OFeb-(#0 0g 06Y.COF ©Primary Owner(s): Name(s):LCM AD Leaner Mailing Address,C/S/Z:sacCellPhone:_()J land Line:_() Email:o O Check if all work will be performed by homeowner only °Installer/Builder:Workers’Comp documentation must be submitted with this application Contact Name(s):___Be<r_2e;Tre FEET VE Contractor Trade: Mailing Address,C/S/Z:(760 Gann Ae.han y UY 0226> Cell Phone:_(S”F_)_#£7-7600 land Line:_() Email: Contact Person for Building &Code Compliance: Cell Phone:_()Land Line:_( Email::; |||JAN 24 2020 Fuel Burning Appliance &Chimney Application Revised February 2019 FUEL BURNING APPLIANCE INFORMATION: TYPE OF DEVICE:e __Stove __Fireplace Insert _Viireplace __Fuel Fired Equipment (Garage Only,18”clearance per IMC 304.3) __Fireplace,factory built** (**Manufacturer’s name:Model #:) SOURCE OF HEAT: __Wood ___Coal __Pellet _Yas frclonte CHIMNEY INFORMATION: ___Masonry (require plans to be submitted): block __brick —___stone __Flue: __tile __steel ___size,in inches _Material*: __double-wall —__triple-wall__insulated ("Manufacturer's name:Model #:) 1.Two inspections are required.A rough-in inspection,prior to installation and a final inspection,after installation. 2.Manufacturer's installation manual must be available at the time of inspection. 3.Masonry fireplaces &chimneys require plans to be submitted. 4,Twenty-four (24)hour notification is required for inspections. 5.Workers’Comp insurance information is required with this application. ‘onstruction/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. Ihave read and agree to the above: PRINT NAME: ‘SIGNATURE:pate:“27-20 Fuel Burning Appliance &Chimney Application Revised February 2019