FMP-0873-2021 FUEL BURNING APPLIANCE& office use only
CHIMNEY APPLICATION Permit#: FM� -DgI-S- 20'L
Permit Fee:$
Town ofQuecnsbury
742 Bay Road,Queensbury, NY 12804 Invoice:#: `-�
P:518-761-8256 www.gueensbury.net
Project Location: 14 3 rdwd Tax Map ID#: -t ^ 3 • ��
i ,
Room of Install: 41r6olvl Planned Install Date:
**ONE APPLICATION PER APPLIANCE*.* _
EzE0VS
CONTACT INFORMATION: DEC 10 2021 i
9 Applicant: � . f
-Ir TOWN 4F QUEENSBURY
Name(s): J�- �� E�40, BUILDING.&CODES
Mailing Address, C/S/Z: /f-/3
Cell Phone: f Sy3 ) 3&4- 0g1P3 Land Line: ( )
Email: e.v�-w is \ �' c1 y►rai/, c_c,�
• Primary Owner(s): _
Mailing-Address, C/S/Z: 1Y3y 4W,--e
Cell Phone:_( IG ) 3(eK -CS'1�3 Land Line:
Email'
• Installer/Builder.:
Business Name: ' _ s k IP �-�- t.`✓�ti o�.,�Q C«�i`-�a
Contact Name(s):' J6
Mailing Address, C/S/Z: 3 Ves w v,l
Cell Phone:_(� Land Line: _f S 1 9 )
Email: O�s�'�OL►L. (�_ RV�a� 1� Coy✓+.
Contact Person for Building& Code Compliance:
Celt Phone: (�LLI-5 ) 3&4- O g[x3 _ Land Line:_( )
Email: s & 4i l. tp
Fuel Burning Appliance&Chimney Application -Revised March 2617
FUEL BURNING APPLIANCE INFORMATION: '
TYPE OF DEVICE:
_Stove Fireplace Insert X Fireplace
Fuel Fired Equipment(Garage Only, 18"clearance per IMC 304.3)
A
Fireplace,factory built**
**Manufacturer's name: 4evV t rr> Model#: L `
SOURCE OF HEAT:
_Wood _Coal _Pellet Gas
CHIMNEY INFORMATION:
Masonry:
block brick stone
_Flue:
tie steel —size, in inches
_Material*:
double-wall triple-wall insulated
(*Manufacturer's name: UUY'l�l�-C�v 1 Model#: �� n l/ — � )
ADDITIONAL INFORMATION:
1. Two 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.
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
requited inspections.
I have read and agree to the above:
PRINT NAME: L�" ti
SIGNATURE: DATE:
Fuel Burnin ce&Chimney Application Revised March 2017