Application Office Use Only
MANUFACTURED HOME Permit#: 9-,-- - O3l5-Z-02-1
PERMIT APPLICATION permit Fee:$ _
Town otCleensbury
742 Bay Road,Queensbury,NY 12804
P:518-761-9256 www.gueensburv.net Inv Fee:$
nvoice#: �J�S
Project Location:
17 Gregwood Circle Flood Zone? Y N Reviewed By r v'
Tax Map ID #:
VTOVVNOF
E
Name of Park (if applicable): Forest Park MHC, LLC 0
21
PROJECT INFORMATION:
BURY1. Proposed Date of Placement: 08-01-2021 DES
2. Approximate Value of Home:$ 50,000.00
3. Is the home NEW x or a REPLACEMENT ?
4. Single-wide_ or Double-wide Size: 16 ft.X 76 ft = 1216 total square feet
5. Foundation support(choose one): Size Depth
X Piers: 24' 48'
Slab:
6. Is the home being placed on a private lot? No x Yes**
(**if yes,you must provide stamped engineered drawings of the permanent foundation plan)
7. Total #of rooms(exclude bathrooms): 5 •#of bedrooms: 3 •#of bathrooms: 2
8. Additional heat source? No X Yes_ Choose one, if yes: gas fp_ woodstove_ wood fp
9. Are there any other/existing buildings on the property? No X Yes_; Explain:
10. What is the water source? PUBLIC x PRIVATE WELL_
11. What type of wastewater system is on the parcel? SEWER PRIVATE SEPTIC X
12. Do you need a septic permit application? No x Yes
MANUFACTURED HOME INFORMATION:
(INFORMATION FOUND ON THE PLATE OR STICKER LOCATED IN THE HOME):
Insignia serial #: 112000HDC407234A
Name of Manufacturer: Campion -Tope a
Place approval M
Model or component designation (New Home Only): D01680 RHPH17616
Date of manufacture:
Manufactured Home Application Revised January 2021
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
Applicant:
Name(s): Forest Park MHC LLC
Mailing Address, C/S/Z: 183 Pitcher Road Queensbury, NY 12804
Cell Phone: ( Land Line: ( 518 ) 745-7776
Email: forestpark@rhp.com
Primary Owner(s):
Name(s): Forest Park MHC, LLC
Mailing Address, C/S/Z: 183 Pitcher Road Queensbury, NY 12804
Cell Phone: ( Land Line: ( 518 ) 745-7776
Email: forestpark@rhp com
❑ 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): Dan Hunt/ Hunt Home Services
Contractor Trade: Site Prep/ Home Set Up
Mailing Address, C/S/Z: 36 Brickoven Rd. Queensbury, NY 12804
Cell Phone: ( 518 ) 361-2931 Land Line:
Email: dirtywhiteboy970@yahoo.com
**Workers' Comp documentation must be submitted with this application**
Contact Person for Compliance in regards to this project: Jack Evans- Community Manager
Cell Phone: ( Land Line: ( 518 ) 745-7776
Email: forestpark@rhp.com
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 the above:
PRINT NAME: v AIL U.v.
SIGNATURE: DATE:
Manufactured Home Application Revised January 2021