FMP-0772-2021 FUEL BURNING APPLIANCE & office Use only
CHIMNEY APPLICATION Permit#:
Permit Fee:$
Town of Qucensbury
742 Bay Road,Queensbury, NY 12804 Invoice#:Tip
P:518-761-8256. www.gueensbury.net
**ONE APPLICATION PER APPLIANCE**
Project Location: 00 T f �R Tax Map ID#: _
Room of Install: /—I Vltl)�� 400t( Planned Install Date:
FUEL BURNING APPLIANCE INFORMATION: " Q
D
TYPE OF DEVICE: OCT 1 9' 2021
Stove Fireplace Insert _Fir pla-EPWN OF QUEENSBUF:Y
BUILDING&CODES
Fuel Fired Equipment(Garage Only: 18" clearance per IMC 304.3)
Fireplace,factory built**
(**Manufacturer's name: OUA-w - Model#: 00'76 O6 S'5-1 )
SOURCE OF HEAT: '
Wood Coal Pellet Gas
CHIMNEY INFORMATION:
Masonry(require plans to be submitted):
block brick stone
_Flue:
_tile '' steel _size,-in inches
Material*:
double-wall —triple-wall_insulated
(*Manufacturer's name: Model#: )
Fuel Burning Appliance&Chimney Application Revised December 2020
CONTACT INFORMATION: PLEASE PRINT LEGIBLY,OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): CZ1/Y1517 4(5r e 5 ��
Mailing Address, C/S/Z: Zo
Cell Phone: Land Line:
Email: CW-4,,5.5ri IAIO
• Primary Owner(s):
Name(s): 57r-4-i,)
Mailing Address, C/S/Z: ao 7?E;E� "Ne
Cell Phone:_( S75' 7Yy,:S?6 Land Line: _( )
Email: Cr,PrSsti�� ��1 -�vR^
heck if all work will be performed by property owner only
• Installer/Builder;Workers' Comp documentation must be submitted with this application
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Liner _( )
Email:
Contact Person for any question's regarding this project:
Cell Phone: Land Line:
Email:
ADDITIONAL INFORMATION:
1. Two (2) inspections are required. A-rough-in inspection, prior to installation and a final inspection,
after installation.
2. Manufacturer's installation manual must be available at the time of inspection.
3. Masonry fireplaces &chimneys require plans to be submitted.
4. Twenty-four(24) hour notification is required for inspections.
S. Workers' Comp insurance information is required with this application.
Declaration: Construction/installation must conform to NYS Fire Prevention & Building Code and/or
manufacturer requirements. The applicant or owner agrees to comply with all applicable laws, ordinances,
regulations and all conditions that are part of these requirements and also will allow the inspector to enter the
premises to perform the required inspections.
I have read and agree to the above:
PRINT NAME:
SIGNATURE: �' - SEE _ DATE:
Fuel Burning Appliance&Chimney Application Revised December 2020