FMP-0897-2021 DGCC0VE
IT D 2021
TOWN OF QUEENSBURY
UILDING&CODES
Office use Ornlly' G+
. CHIMNEY APPLICATION Permit U.- r'M r" dgg7^.pQ.?(
Permit Fee:
Town of ucensbun
742 Bay Road,Queensbury,NY 12804 Invoice It:
P:518-761-8256 www.oueensburv.net
**ONE APPLICATION PER APPLIANCE**
Project Location•177 Glen Lake Rd,Lake George NY 19R45Tax Map ID#:SWIS7 52140171 /Tax Ifl 7R8.16-1-88
Room of Install: Living Room Planned Install Date: 12/30/2021
FUEL BURNING APPLIANCE INFORMATION:
i
TYPE OF DEVICE:
✓ Stove Fireplace Insert _Fireplace
`Fuel Fired Equipment(Garage Only: 18"clearance per IMC 304.3)
_Fireplace,factory built**
(**Manufacturer's name: MORSO Model#:MORSO 6140 B WITH LOW BASE
SOURCE OF HEAT:
✓ Wood _Coal _Pellet `Gas
CHIMNEY INFORMATION:
_Masonry(require plans to be submitted):
block brick stone
Flue:
the _steel _size,in inches
Material*:
_double-wall _triple-wall insulated
(*Manufacturer's name: Model#: )
Fuel Burning Appliance&Chimney Application Revised December 202o
pEG` E9 W E
TOWN
�!G&CODES QUEENSB Y
FUEL BURNING APPLIANCE & office use only
CHIMNEY APPLICATION Permit If: Fm P 0897'a?i9a-1
Permit Fee:$
7(nrn of Queens 7
742 Bay Road,Queensbury,NY 12804 Invoice it:
P:518-761-8256 www.gueensbury.net
**ONE APPLICATION PER APPLIANCE**
Project Location:177 Glen Lake Rd,Lake.George,NY 19R45Tax Map ID#:SWIS: 5234001 Tax IM288.16-1-88
Room of Install: Living Room Planned Install Date: 12/30/2021
FUEL BURNING APPLIANCE INFORMATION:
i
TYPE OF DEVICE:
—Stove _Fireplace Insert Fireplace
—Fuel Fired Equipment(Garage Only:18"clearance per IMC 304.3)
' Fireplace,factory built**
i -
(**Manufacturer's name: Model#: )
SOURCE OF HEAT:
_Wood _Coal _Pellet _Gas
CHIMNEY INFORMATION:
Masonry(require plans to be submitted):
block brick stone
✓ Flue:
—tile ✓ steel 6 size,in inches
Material*:
double-wall _triple-wall_insulated
(*Manufacturer's name: National Chimney Model#: M-Flex. )
Fuel Burning Appliance&Chimney Application Revised December 2020
I
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): Frank Hax
Mailing Address,.C/S/Z: 5 West 37th Street,l9th Floor, view erk,ly 4C) 18
Cell Phone: 646 ) 3000868 Land Line: N/A )
Email: frank(ci)stayatlina.com -
• Primary Owner(s):
Name(s): 177 Glen Lake_ Road. LLC
Mailing Address,C/S/Z: 5 West, 37th.Street,12th Floor, New York. NY 1()01R
Cell Phone:_( 646 ) 542 4740 Land Line: _( N/A )
Email: albert stayatlina c orn
El Check if all work will be performed by property owner only
• Installer/Builder:Workers' Comp documentation must be submitted with this application
Contact Name(s): Champs Chimney Sweep, LLC
Contractor Trade:_ Chimney-Liner Installation
Mailing Address,C/S/Z:175 Broad Street Suite 29S,GIens Falls New Ynrk 12801
Cell Phone:J.).+15183384381 Land Line: '—( N/A )
Email: bob(D_champschimneyxom
Contact Person for any questions regarding this project: Frank Hax
Cell Phone: 646 ) 300 0868 Land Line: ( N/A )
Email:_frankCo)stayatlina.com
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 8t 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: 177 G
SIGNATURE: DATE: 12/28/2021
Fuel Burning Appliance&Chimney Application Revised December 2020