RC-0238-2022 :r
Office Use Only
MANUFACTURED HOME Permit#: Q-G ^0258•ZZ2.
PERMIT APPLICATION permit Fee:$ 2152.•
Torn orQucensbury
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.gueensbu[y.net Rec Fee:$ Pt' ojn.vAry�
Invoice
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Flood Zone? Y DReviewed By�
Project Location: 4LA1A L Seefvyl- 2A
Tax Map ID#: 309 CA--
Name of Park(if applicable): y O c`J\w A.S
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PROJECT INFORMATION:
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1. Proposed Date of Placement:
3. Is the home NEW or a REPLACEMENT x '
4. Single-wide or Double-wide Size: 1"1 ft.X -7 —ft._ qk�le total square feet
5. Foundation support(choose one): Size Depth 1008
Piers:
Slab:Y
6. Is the home being placed on a private lot? No /` Yes**
(**if yes,you must provide stamped engineered drawings of the permanent foundation plan)
7. Total#of rooms(exclude bathrooms): _;#of bedrooms: .2 ;#.of bathrooms: ?
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 PRIVATE WELL
11. What type of wastewater system is on the parcel? SEWER PRIVATE SEPTIC
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#: Do - ddo- 1 t-- A n 4
Name of Manufacturer: C�`n Fri f
Place approval#:
Model or component designation.(New Home Only): _
Date of manufacture: ��
Manufactured Home Application Revised March 2022
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CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• A (�icant: �V(
Name(s):, _ Georcle Dreflos
Mailing Address,C/S/Z: _ _
Cell Phone:_(��g} �(�- 3 G Land Line: _ S I Ff- Y1 S~ q5_
Email:— - G��l -61 &G T 0 f CCU
• Primary Owner(s):
Name(s): �-,5h i } `
Mailing Address, C/S/Z:- Vt,2,5k r1/1oun+Glf' Qye2nSLour�1 I? SAC
Cell Phone: (55 )?Z7 2.91 9 Land Line: ._____)
Email:
❑ 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): o-�- l�aJl -
Contractor Trade: -
Mailing Address, C/S/Z:2Jo5\
Cell Phone:��} Land Line: (5t8 ) 1-2-0 2Z>
Email: kc
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* Workers' Comp documentation must be submitted with this application"
Contact Person for Compliance in regards to this project: peocq
Cell Phone: ND -1 Land Line: S l �-)
Email: G ��� f ®s ' Vi'1G1 COm
Manufactured Home Application Revised March 2022
REQUIREMENTS FOR SUBMITTAL:
1. Completed Manufactured Home permit application
THREE (3) COPIES (2 paper & 1 Of OR 3 paper) 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 Or 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:.'
SIGNATURE: -:—.L-4z�Zlllll- DATE::
Manufactured Home Application Revised March 2022
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'UN 2 5 2022
TOWN OF QUA c0® S Y
BUILDING&
CO;t MON1�4EALTH ELECTRICAL INSPE['MON SIGIiVICE,•INC.
e Main O ier.116 Dot:Run Road-Manhcitn,PA Y15a5 M
ie�dji;�i>l�CpP�,I,CEIZ' IFICA'dE - ELECTRICAL APPROVAL
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The condirhms followiou govcmcd tw issuance of this certificate,and any ceR6Ge9te previously issued is
3�;�5•.'t cancelled:- ;•• y
This Cortiti4uiv vuly c(Mrs the iJoctrical ogmpm¢nt and installation t:onditions as of date. Upon the :•'•,?
introduction of&ekiilif=l equipment or,Ircralioils,application Shull bo promptly made for inspection. �.
[iwgpector of this C'ornpuny shall have the privilego of mating hispections at al time, and if iL
rules are violetod. ilia Company shill have the right lo.revoke this certificate.
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