application Office Use Only
MANUFACTURED HOME Permit#: — 202'0
PERMIT APPLICATION \Queensbury Permit Fee:$ 2 iJ- 1/47
Town of
742 Bay Road,Queensbury,NY 12804
Rec Fee:$ N R-
P:518-761-8256 www.queensbury.net
Invoice#: ►\4k
Project Location: 39 O FL ICS Tax Map ID #: 6>3 LfOO ,30,5, fj`1- I —?
Name of Park: Proposed Date of I� e:•,e f:3 7 [5 1 \ i`
� C`- iaf L'.
•
f11U62720LL; 1
CONTACT INFORMATION:
TOWN OF QUEEN.E__URY
• Applicant: iI'D r1C :'�
Name(s): -Darr 1✓1 w 1II1(XYY\S k Jac-1-t min.
Mailing Address, C/S/Z: C\ DC C�V) 2ci QUeensbuY9 ) (�--J a DLI
Cell Phone: ( 51$ ) - CA cO(u Land Line: ( )
Email: 1(Y\CLIY1 CA d CI ZCOly e c sn , C' D Yl
• Primary Owner(s):
Name(s): DC'�\C L\\i-\ \\\\(3,►r,(1 S 4 AGC\LL.e.
Mailing Address, C/S/Z: ?-)q C7 root') Q0e,Pr-Ndou , tv� (a
Cell Phone: (51 iS ) y(G1 C� jo Land Line: ( 1
Email: 0.,(`(\O d d 2_QCta C \C.t\r oo -
❑ Check if all work will be performed by homeowner only
• Contractor(s): C 0nescif,I 5\ C '
Contact Name(s): S(rah) c 0, Ctcfreri , L LC
Contractor Trade: CA ..5. 1nD ULS / 1 id(- K �(CJ13Y
Mailing Address, C/S/Z: ' C ►etwAc_)i 0..E IDQo( 1 ,ch 1 f wa tr t i I ,Q .)—) e)
Cell Phone: ( ) Land Line: ( 511S ) GAO4 -a a513
Email:
**List all additional contractors on the back of this form
Contact Person for Building & Code Compliance: Cue ii61‘ Clunt.
Cell Phone: ( ) Land Line: ( )
Email:
Manufactured Home Application Revised February 2019
•
•
•
M 0 /\ c.\
• Contractor(s): �`nS��.A, � I /� ,c
Contact Name(s): C, Of1b5 -This c c C>hj c \ - CDMVIS
Contractor Trade: \v'UCckAVfc j \ns eh�f1
Mailing Address, C/S/Z: LP ql\nc\osenQ 1 Q0ecYl.goi.XLA ► 12104
Cell Phone: ( ) Land Line: ( 51 ) '161 a S"7 S'Q
Email:
• Contractor(s):
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: (
Email:
• Contractor(s):
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: ( )
Email:
• Contractor(s):
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: ( )
Email:
• Contractor(s):
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: ( )
Email:
• Contractor(s):
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: ( )
Email:
Manufactured Home Application Revised February 2019
MANUFACTURED HOME INFORMATION:
(INFORMATION FOUND ON TTHE PLATE OR STICKER LOCATED IN THE HOME):
Insignia serial#: cl)L R) I J
Name of Manufacturer: C DX.Y\
Place approval#:
Model or component designation (New Home Only): ASbcp
Date of manufacture: 2,0k Z ,
ADDITIONAL INFORMATION:1. Approximate Value of Home:$ L9"I I—1-1
50
2. Is the home NEW or a REPLACEMENT y ?
3. Single-wide or Double-wide ; Size: ft.X S(p ft.
4. Foundation support(choose one): Size Depth
Piers: 11
Slab: -Ij`cq r1 11
5. Is the home being placed on a private lot? No Yes X (if yes,you must provide stamped engineered
drawings of the permanent foundation plan)..
6. Total#of rooms (exclude bathrooms): ( ;#of bedrooms: 3 ;#of bathrooms: a
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 Yes IC; Explain: V
9. What is the water source? PUBLIC PRIVATE WELL
10. Is the parcel on SEWER or a PRIVATE SEPTIC system? P(\'OC\ ' ' C
11. Do you need a septic permit application? No 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: 11_,V1A)k lctf,;S
SIGNATURE: DATE: `78'
,i)
Manufactured Home Application Revised February 2019