Application Office Use Only
WL MANUFACTURED HOME Permit#:
PERMIT APPLICATION permit Fee:$
to m erczyeenylwry
742 Say Road,Queensbury,NY 12804 Rec Fee:$
P:518.761-8256 www.aueensbury ngt
Invoice#:
yY ui wJS�.r Pr��� Flood Zone? Y Reviewed By:
Project Location:
Tax Map ID 4: 2DOI
Name of Park (if applicable): d l/f i
PROTECT INFORMATION: D u 'y
1. Proposed Date of Placement: MAY p J 2021 D
2. Approximate Value off ome:$��� TOhV/y OF
3. Is the home NEW/✓ or a REPLACEMENT_? /� BUILDING&ECONDESRY
4. Single-wide ✓ or Double-wide_; Size: �ft. X ft._ %�� total square feet
5. Foundation support(choose one): Size Depth
✓ Piers. ray 1_00n0 la it
_Slab:6. Is the home being placed on a private lot? No✓/ Yes**
(**if yes,you must provide stamped engineered drawings of the permanent foundation plan)
7 Total#of rooms(exclude bathrooms):_� #of bedrooms: 3 :#of bathrooms: _
S. Additional heat source? No_/Yes_ Choose one, If yes: gas fp_ woodstove— wood fp_
9. Are there any other/existing buildings on the property? No V Yes�; Explain:
10. What is the water source? PUBLIC_Z PRIVATE WELL_
11. What type of wastewater system is on the parcel? SEWER _ PRIVATE SEPTIC
12. Do you need a septic permit application? No V/ Yes_
MANUFACTURED HOME INFORMATION:
(INFORMATION FOUND ON THE PLATE OR STICKER LOCATED IN THE HOME):g
Insignia serial M ® 1 / l 0 "C') " 14 — 140U S 6 1 U /4'
Name of Manufacturer: /, "t eS
Place approval#:
Model or component designation (New}ome Qnly): 7�!
Date of manufacture: / 2 ? )
Manufactured Home ApPICadon Revised January 2021
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): G 2tt
Mailing Address, C/S/Z: PO ✓a-1 AAK /11q1`/
Cell Phone: ) Land Line: f sa's ) G l/ DC;3r_g
Email: iC'e I-e- P es
11
Primary Owner(s):
Name(s): �i� ,l U1 flic:Lre C G .
Mailing Address, C/S/ X 7.5�9 ✓o+� , A, " `y`//`
Cell Phone: �_) Land Line: 4�9 of Zv/4
Email:7re/T10,aQ / ho-~s , e,,,,..-. ,
❑ Check if all work will be performed by the property owner only
• Contractor(s): (List all additional contractors on the back of this form)
Contact Name(s): /g61- l& woS, Z-2 c .
Contractor Trade: et 00 • - rdG.e A
Mailing Address, C/S/Z: _ �x -lS9 /S7✓rn + A)k /yyl
Cell Phone: ) Land Line: ((,S Dx 31,7
Email: . rei a qp 4o-"7 s .dCp,4-t-r .
** orkers' Comp documentation must be submitted with this application**
Contact Person for Compliance in regards to this project: �-CV 12-e4Jc 4
Cell Phone: A Land Line: ("S' ) ,2�24 ^4,o"/S6 X,3
Email:-4 !!ble C4 as tid>'«S , eir'^7
Manufactured Home Application Revised January 2021
REQUIREMENTS FOR SUBMITTAL'
1. Completed Manufactured Home permit application
THREE (3) COPIES OF THE FOLLOWING:
2. Structural drawings, which include:
a. Floor plan
b. Foundation plan (see 2015 IRC Appendix E Section AE502: foundation systems)
c. If the home is being placed on a private parcel (not in a manufactured home park or designated
zone),you MUST provide stamped engineered drawings of the permanent foundation plan.
3. Plot plan, using a survey map if possible,which includes:
a. Drawn to scale (i.e. 1 Inch = 30 feet)
b. Indicate proposed location, with setbacks
c. Include all structures on the property
d. Include location of water supply (well or water lines)
e. Include location &configuration of septic system or sewer line
ADDITIONAL SUBMITTAL INFORMATION:
1. Installer Warranty seal must be provided prior to issuing Certificate of Occupancy.
2. Any changes to the approved plans prior to or during construction will require the submittal of
amended plans, additional reviews and re-approval.
3. If, for any reason, the building permit application is withdrawn, 30% of the fee is retained by the
Town of Queensbury. After 1 year from the Initial application date, 100% of the fee is retained.
4. Workers' Comp insurance information for all contractors involved—REQUIRED, EVEN FOR SOLE
PROPRIETORS
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 complied with,whether specified or not,and that such work is authorized by the owner.
I have read and agree to three above:
PRINT NAME: �tjl
SIGNATURE: ['��G%n�l ir �/ DATE:
Manufactured Home Applicauon Revised January 2021