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RC-0483-2020 Y a. - Office Use Only 4/0166. MANUFACTURED HOME Permit#: {.0 7QZt� PERMIT APPLICATION Town ofQuec sn bury Permit Fee:$ -5U .40 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.queensbury.net Rec Fee:$ N lam' Invoice#: "2..cf© • Project Location: LrrA 06) Ae kL M V( I/Tax Map ID #: ,L'"--149 Name of Park: ( Giteelt-S d�Ula-- (sit ( .0 Proposed Date of Placement: A p irCEfiviEfi CONTACT INFORMATION: 1111 AUG ) 8 2020j pj • Applicant: TOWN OF �— BUILDING& CODES Name(s): / 11�1� )I'�6I,tSI'Ll Gtu(� .. ....__. MailingAddress, C S Z: L( ft�1/4- /Oi0 tifl/it5mi A) / / Cell Phone: ( 5( ' ) Land Line: ( T5 ) Email: MA' ▪ Primary Owner(s): Name(s): jF9 y 1,601-(-idb"2 Mailing Address, C/S/Z: 13F) iT -ff aSe I O y ., Cell Phone: ( 54V ) Sqs Land Line: ( ) TIT2g2)1 Email: vpi) � h ales < CD& ❑ Check if all work will be performed by homeowner only • Contractor(s): Contact Name(s): (9 w_A)& et( (S i 14 yew Contractor Trade: 14 6Try Lrf 4 i 2ed7 f4cy 3/9-/€-5 Mailing Address, C/S/Z: 13t)4 /'V‘v / ZS5' 1 Cell Phone: ( ) Land Line: ( ') '-)1 2Z- )1 Email: **List all additional contractors on the back of this form Contact Person for Building & Code Compliance: Cell Phone: ( 5 l$ ) Ss-7 e''7r Land Line: ( ) Email: Manufactured Home Application Revised February 2019 ,16 MANUFACTURED HOME INFORMATION: (INFORMATION FOUND ON THE PLATE OR STICKER LOCATED IN THE HOME): Insignia serial #: _ l Name of Manufacturer: 4)016 Place approval#: Model or component designation (New Home Only): Date of manufacture: ADDITIONAL INFORMATION: 1. Approximate Value of Home: $ 95 irOr E 2. Is the home NEW �or a REPLACEMENT ? 3. Single-wide or Double-wide ; Size: rpLt ft.X 5 ft. 4. Foundation support(choose one): Size Depth Piers: Slab: � 1 b 5. Is the home being placed on a private lot? No Yes (if yes,you must provide stamped engineered drawings of the permanent foundation plan) 6. Total#of rooms(exclude bathrooms): : #of bedrooms: - ;#of bathrooms: 7. Additional heat source? No Yes Choose one, if yes: gas fp_ woodstove_ wood fp 8. Are there any other/existing buildings on the property? No 7 Yes ; Explain: 9. What is the water source? PUBLIC PRIVATE WELL 10. Is the parcel on SEWER or a PRIVATE SEPTIC system? Pp( V 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: 5A m W 1 11"C/CP) SIGNATURE: DATE: te,—20 Manufactured Home Application Revised February 2019 I I I I I I I I , I I I I I I I I I • I . I I I 1 I I I I �I I I I II I I �.,0 _L I 1 m�Q Ti I �— c1� 1 _ _ Li_ • ,?.e_ rc-- 1 . • . T 7 ___ 1 fp?" I '''si I T T I I I . r� I I 11 . 1 I I 1 I I I I I I . I I I I I . 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