RC-0545-2021 s e
Office Use Only
MANUFACTURED HOME Permit#:
r . ��-
-- � PERMIT A� � C�T�O,IV� Q Ir it Fee: $ Z��. UO
Town of Qeensbury !�
742 Bay Road,Queensbury,NY 12804 14 A
=L' 2
Fee:$
P:518-761-8256 www.gueensbury.net
I'nv ice#: l
ifhda�soc,Ji 11 TOWN O1=QUEEi'�SBUR
DL!�'�`iGrS Flod Zone? Y 4� Reviewed By
Project Location: t\ C- �•
Tax Map ID#: C,2
Name of Park (if applicable): POVA4400 V d I aLR y—
PROJECT INFORMATION:
1. Proposed Date of Placement:
2. Approximate Value of Home:$ 30 ,ac d
3. Is the home NEW V or a REPLACEMENT ?
4. Single-wide Y or Double-wide Size: P LI ft.X 6,Y ft. = 7 195a— total square feet
5. Foundation support(choose one): Size Depth
V Piers:
Slab:
6. Is the home being placed on a private lot? No Yes** v
(**if yes,you must provide stamped engineered drawings of the permanent foundation plan)
7. Total#'of rooms(exclude bathrooms): ;#of bedrooms: 3 ;#of bathrooms: Z
8. 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 Yes ; Explain:
10. What is the water source? PUBLIC V PRIVATE WELL
11. What type of wastewater system is on the parcel? SEWER PRIVATE SEPTIC •
12. Do you need a septic permit application? No +' Yes
MANUFACTURED HOME INFORMATION:
(INFORMATION FOUND ON THE PLATE OR STICKER LOCATED IN THE HOME):
Insignia serial#:
Name of Manufacturer: dwAa yikZ4,� ass i
Place approval#:
Model or component designation (New Home Only): P
Date of manufacture:
Manufactured Home Application Revised January 2021
Y
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): �O5N y c. C I S
Mailing Address, C/S/Z: 16 6 E 1 m hot'5+ D K 1I 1bg
Cell Phone: C. $ ) 311 KI "W Land Line:
Email: Q 4&1 . covet
MAAIIA 4-.VK
• Primary Owner(s):
Name(s): t�eau) tldllo. .�
Mailing Address, C/S/Z: _3�0 LUZ-W'- QvnrembyKy-eAVY l'Z"'-t
Cell Phone: ( SIX ) 711 TO V Land Line:
Email:�JL%Vq1 a- amp-'gil►'cow
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):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: �_) Land Line: � )
Email:
"Workers' Comp documentation must be submitted with this application"
Contact Person for Compliance in regards to this project: ►c1w`' r-.-�
Cell Phone:�_) Land Line: � )
Email:
Manufactured Home Application Revised January 2021
i
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: O C r JP-- I S
SIGNATURE: DATE: 0.G
Manufactured Home Application Revised January 2021
P
10
Champion Home 8ullders,Inc.
Quote-Revision 1
951 Ate.12 South No.: OT033113
Sanger![old,NY 13455
Phone:31&841A122 Quote Date: 08/24/21
Fax:31&841.4560 1391aller P.O.:
order Type: Retail
Retail Customer: Lot#116
810 70: 1057NY Sell To: 0950NY RegrDel.Date:
Affordable Great Locations,Inc, Affordable Great Locations,Inc, zone Manager: Jim Davis
Affordable Great Locations,Inc. Homestead Village MHP Btand: TITANS EAST POINT
4306 Route 5 200 Luzeme Rd Model No.: EP8144
Caledonia,NY 14423 Queensbury,NY 12804 Base Home: 14X72$BR 213ATH
Shawn Adams Model Year: 2022
Model Size; 68'0"X 13W
Construction Type: HUD
Shipping Agent:
Shipping County: WARREN
FOB: Factory
Page:1 of 4
Feature Option Variant Description Quantity Ext.Price
Construction
WINDZONE 10198 WINDZONE 1 1 Standard
ROOFINS 621 R•30 ROOF INSULATION 907 Standard
ROOFLOAD 10003 30 LB ROOF W/24 OC RAFTER 70 Standard
ROOFPITCH 999 3112 ROOF PITCH 70 Standard
FLOORINS 13979 R•11 FLOOR INSULATION 1 Standard
FLOORJST 13M 2X6 FLOORAOISTS IS-O/C 1 Standard
SHEATHING 14003 FOAM-CORE SHEATHING 1 Standard
WALLINS 109 R-19 WALL INSULATION 1 Standard
SWALLHT I0077 8'SIDEWALL 1 Standard
FRAME 13480 V'RECESSED FRAME•• 1 Standard
HITCH 9 REMOVABLE HITCH-PER FLOOR 1 Standard
OTHER 10001 CONTINUOUS RIDGE VENT 1 Standard
Plumbing/Heating
HEATSYS 10044 White GAS FURNACE(ATMO-GAS) 1 Standard
DUCTSYS 12336 IN LINE HEAT FLOOR REGISTERS 1 Standard
WH 10001 30 GALLON ELEC.WATER HEATER 1 Standard
WHACCESS 10117 DRIP PAN FOR WATER HEATER i Standard
OTHER 279 WATER SHUT OFFS&MAIN 1 $5.00
OTHER 323 PLUMB&WIRE FOR WASHER 1 Standard
OTHER 3442 ROOF JACK EXTENSION 1 25.00
OTHER 379 EXTERIOR FROST FREE FAUCET 1 - 40.00
Champion Is a mOstwed trademark at Champion Flom Builders,Inc.
* i
Quote-Revision i-No.:OT033113 Model No.. EP8144 Page:2 of 4
Feature Option Variant Description Quantity Ext.Price
Exterior
FRONTDOOR 10188 White 36M FRONT DOOR 1 Standard
KEYSTONE
RHH
REARDOOR 13340 White 36'9-LITE 1 375.00
KEYSTONE
RHH
SHINGLES 13i38 Dual Black 3-Tab Shingles 14 WIDE 70 Standard
SIDING 14280 SELECT VARIANT DOUBLE V VINYL SIDING (i 1,362 Standard
OTHER 13458 White STORM DOOR 1 252.00
LH14
OTHER 14206 NON GRID WINDOWS EA. 1 Standard
OTHER 14289 TRADITIONS FRONT END 1 250.00
(11)WHITE RESTORAT10NISILLWORK PILLAR
LINEAL HE IMIVDOW(NO SHUTTER):WHITE
SIDING COLOR BETWEEN PILLAR AND CORNER:SAME AS SIDING COLOR
INCLUDES 2 OUTDOOR LANTERN LIGHTS
OTHER 638 SELECT VARIANT EXTRA RP SHUTTERS-PER SETT 3 114.00
OTHER 733 ICE GUARD 1 219.00
Electrical
MAINPANEL 10042 i00 AMP SERVICE 1 Standard
OTHER 10023 LIGHTS @ ALL EXTERIOR DOORS 2 Standard
OTHER 10048 EXTERIOR GFI RECEPTACLE 1 Standard
OTHER 13713 HUNTER PADDLE FAN 1 195.00
OTHER 14117 USS RECEPTACLE 1 30,00
OTHER 325 WIRE A VENT FOR DRYER 1 Standard
OTHER 560 CARBON MONOXIDE DETECTORS 1 80.00
Interior
DOORS 13598 WHITE 2-PANEL INTERIOR DOORS 1 Standard
DR)AMBS 10200 Umber Oak DOOR JAMBS STO I Standard
FLRCOVER 13596 Brownwood LIVE WIRE CARPET 66 99.00
ORMOLDING 10213 Umber Oak FLAT DOOR MOLDING 1 Standard
CLGCOVE 10212 Umber Oak FLAT CEILING MOLDING 1 Standard
LOCKSETS 10063 METAL DOOR KNOBS 1 Standard
CEILINGFIN 10011 STIPPLE TEXTURED CEILING 1 Standard
OTHER 10009 WIRE VENTED SHELF-ALL CLOSETS i Standard
OTHER 13812 MINI-BLINDS PER WINDOW 6 150.00
OTHER 13675 Umber Oak KF-104 W1 MDF DOORS AND STILES 1 215.00
Kitchen
DRYWALL 10025 Northwood Mineral VNL CLD GYPSUM WALL BOARD 26 Standard
FLRCOVER 14419 AF010-Woodgrain ARMOURFLOOR LINOLEUM is Standard
CABtNETDR 10065 Umber Oak MDF CABINET DOORS 9 Standard
CABSTILES 12883 Umber Oiled Oak MDF CABINET STILES 1 Standard
CTRTOP 1228E Madura Pearl LAMINATE COUNTERTOP 12 Standard
EDGE 12287 FORMICA EDGING 1 Standard
SINK 10034 Stainless Steel STAINLESS STEEL SINK-KITCHEN 1 Standard
Chempron is it tagiarerod trademark or Champfan Rome Builders,1.4a.
1
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Quote-Revision 1-No.:OT033113 Model No.: EPS144 Page.3 of 4
Feature Option Variant Description Quantity Ext.Price
Master Bath
DRYWALL 10025 Northwood Mineral VNL OLD GYPSUM WALL BOARD 22 Standard
FLRCOVER 14419 AF01a-Woodgraln ARMOURFLOOR LINOLEUM 6 Standard
CABINETDR I0065 Umber Oak MDF CABINET DOORS 1 Standard
CABSTILES 12883 Umber Oiled Oak MDF CABINET STILES 1 Standard
CTRTOP 12286 Madura Pearl LAMINATE COUNTERTOP 3 standard
EDGE 12287 FORMICA EDGING 1 Standard
SINK 546 CHINA SINK 1 47,00
TUB 10118 t PC F113EAGLASS TUB 1 Standard
Hall-Bath
DRYWALL 10025 Northwood Mineral VNL OLD GYPSUM WALL BOARD 25 Standard
FLRCOVER 14419 AFM-Woodgraln ARMOURFLOOR LINOLEUM 6 Standard
CABINETDR 10065 Umber Oak MDF CABINET DOORS 1 Standard
CABSTILES 12683 Umber Oiled Oak MDF CABINET STILES 1 Standard
CTRTOP 12286 Madura Pearl LAMINATE COUNTERTOP 3 Standard
EDGE 12287 FORMICA EDGING 1 Standard
SINK 546 CHINA SINK 1 47.00
'PUB 110ils 1 PC FIBERGLASS TUB 1 Standard
Living Room
DRYWALL 10025 Northwood Mineral VNL CLD GYPSUM WALL BOARD 74 Standard
Dining Room
DRYWALL 10025 Northwood Mineral VNL OLD GYPSUM WALL BOARD 13 Standard
Master Bedroom
DRYWALL 10025 Northwood Mineral VNL OLD GYPSUM WALL BOARD 62 Standard
2nd Bedroom
DRYWALL 10025 Northwood Mineral VNL OLD GYPSUM WALL BOARD 49 Standard
3rd Bedroom
DRYWALL 10025 Northwood Mineral VNL OLD GYPSUM WALL BOARD 54 Standard
Utility Room
FLRGOVER 14419 AF010"Woodgraln ARMOURFLOOR LINOLEUM 4 Standard
DRYWALL 10826 Northwood Mineral VNL OLD GYPSUM WALL BOARD 24 Standard
WASHEROVHD 2862 WASHER/DRYER SHELF 1 20.00
Foyer
FLRCOVER 14427 A17010-Woodgraln ENTRY LINO ARMOURFLOOR 1 65,00
Appliances
RANGE 14733 S.S.GAS RANGE" t Standard
REFER 14731 83,ISCU REFER" t Standard
DISHWSHR 14735 S.S.DISHWASHER- 1 445.00
MICROWAVE 10028 SELECT VARIANT VENTED/LIGHTED HOOD 1 Standard
— etwpian is a registered voarw,k of Cheavlon Homo aulwars,Ina
� 1
Quote-Revision 1-No.:QT033113 Model Na: EPS144 Page:4 of 4
Feature Option Variant Description Quantity EXI,Price-
Inflation Protection Plan
DISCLOSURE 14739 IPP DISCLOSURE i
This home hl subject to an lnlistion protection plant pp)at the time of
Involving.77M quoted amount includes an IPP surcharge of 10%above
ourbase price.The final Involce price will be adjusted in accordance,
Kith IPP.
MISCELLANEOUS CHARGES
STATEDUES STATE DUES 130 13D.00
HUD LABEL 14103 HUD LABEL 1 150.60
SURCHARGE 1.4710 Surcharge 907 8,4K59
HUDL.ASELi 994B NEW YORK STATE WARRANTY SEAL 1 150.00
DISCOUNT 1B8 Discount 375 •376.00
INFLATION 14708 INFLATION PROTECTION PLAN 3,704 3,704.00
Requested By: Shawn Adams BASE PRICE. . . . .. .. . . . . . . . . . . . . . . . .$ 20,632.00
It Is the retaliates reeponsibillty to verify the options and the pricing of OPTION TOTAL. . . . .. . . . . . . . . . . . . . . . .$ 2,73300
the home, MISCELLANEOUS CHARGES . . . . . . . . . . . . . .$ 12,267.80
SALES TAX(IF APPLICABLE) . . . . . . . . . . . . . .$ 0.0D
Champion Home Builders,Inc ryes The right to_make changes at
anytimeln pdoes d spec att s without notice and/or obligation.
SIGNED . . . . . . . . . .. .I . . . . . . . . . . . . . . . .
-' TOTAL FREIGHT CHAROFS . . . . . . . . . . . . . . . 1,750.00
DATE b S d TOTAL PRICE . . . . . . . . . . . . . .$ 45,272.59
NbdiBsd Oats:fl6+24Y21 Ae10(nm0 Pdn[od:06r1A12104:17 PM Modiood 9y:J6VOAVAS
Champion is a repisteted ttadamatkol Champion Home eultdeta,lam.
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Purchase Authorization
PO Number: 21610'
Purchaser: Seller:
AGL Homes, Inc. . Titan
4305 Route 5 951 Rte 12 South-
Caledonia,NY 14423 PO Box 177
(585)226-2727 Fax (585)226-8909 Sanger0eld,NY 13455
Attention: Jim Davis (800)937-3911 Fax: (315) 841-4660
AGL Homes agrees to purchase the following unit,described as Model# 8144
Serial# ,for exactly $45,272.59 . AGL Homes further
authorizes TITAN to submit this unit for floorplaning through
218t Mortgage Cash Program for the exact amount of $45,272.59 . The described
unit shall not be submitted for payment to the floorplan source prior to actual shipment,
unless otherwise authorized by Russ Corey.
Customer and Delivery Information:
Delivery Address:
Customer Name: 21St Model H-6westesd Village
Expected Delivery Date: 116 Adirondack St
Order Number: Qgc usbury NY 12804
AFFORDABLE GREAT LOCATIONS, INC. MUST BE -NOTIFIED IN
WRITING OF ANY PRICE INCREASES ABOVE AND BEYOND THE
PURCHASE AMOUNT AS AUTHORIZED ABOVE, AND SUBSEQUENTLY,
A NEW PURCHASE AUTHORIZATION FORM MUST BE COMPLETED
AND SIGNED, IF ACC LTE AGL HOMES.
Sales Manager Signature: ' -- Date: d
Service Manager Signatu e: Date: I J
Project Coordinator Signatu Date:
General Manager Signature: Date:
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