application FUEL BURNING APPLIANCE & Office Use Only
)4 • CHIMNEY APPLICATION Permit#: f f c5— � - -2O7G
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� emit Fee:$ / Z5 •00
Town of CLuccnsbury
BayRoad, SEP 15 2020Lfoe:m
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742 Queensbury, NY 12804
P: 518-761-8256 www.oueensbury.net
TOWN OF QUEENSBURY
Project Location: X2 Bat,i b .B ,tii!'=`4 algabn ID#:J .3 9 jd 6.5O- I-a`7
Room of Install: L_ ii() e_o-014,___ Planned Install Date: I dI 1 I ZQ C)z a f,
**ONE APPLICATION PER APPLIANCE**
CONTACT INFORMATION:
O• Applicant:
Name(s): John ya±aw
Mailing Address, C/S/Z: o?G 0az ybr i dy,- DeI'e titeeeisZoi,y, /ty /21-0
Cell Phone: (,5JP- ) , /F -- P 1'9 Q . Land Line: . ( ) ,---
Email: `a,cxya f 9..3e 3 iii 411. cernri
• Primary Owner(s):
Name(s): - S A 4
Mailing Address, C/S/Z:
Cell Phone:_( ) , Land Line: _( )
Email:
0 Check if all work will be performed by homeowner only
• Installer/Builder: Workers' Comp documentation must be submitted with this application
Contact Name(s): -F e-s i e fc e_e p i:,La s L[L
Contractor Trade: (3 t4-P_.
Mailing Address, C/S/Z: L17 S . Co‘(‘i&-4-t, Pgac(
Cell Phone:_( Land Line: _(5iS ) 79g, z Z2zj
Email: S fildi,cfVvcsvA@. c s+-. f lam- facets r co vv..
Contact Person for Building & Code Compliance: -
Cel l Phone: ( ) Land Line: (5-re ) ?R r- ZZ Z 5
Email: c Gicu.✓o -@ rs fri ce,r t r,ep (a rep) , crime
(TURN OVER)
Fuel Burning Appliance&Chimney Application Revised January 2020