RC-0774-2021 r Office Use Only
MANUFACTURED HOME Permit#: O 2(
-u _PERMIT APPLICATION Permit Fee:$
Tom of Queensbury
742 Bay Road,Queensbury,NY 12804 .
Rec Fee:$ � �" u.
P:518-761-8256 .www.gueensbury.net I., . !
Invoice#• 1 ?bz?)
Flood Zone? Y N Reviewed By:
Project Location: ' sa-,Vide_YS ILCIt a
Tax Map ID#:—"'0 '= 61- 1 '7 __.
Name of Park(if applicable): �r..va.)nL nn E C E 9
PROJECT INFORMATION: OCT 2 0 2021
1. . Proposed Date of Placement: fi � ��� TOWN OF QUEENSBU�Y
r BUILDING&CODES
2. Approximate Value of Home: 00- 0
3. Is the home NEW or a REPLACEMENT :/ ?
4. Single-wide or Double-wide Size: ' �S ft.X 2Q ft.= 15 total square feet
5. Foundation support(choose one): Size Depth
�� 1 v
Piers: +
Slab:
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: 3 #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 V/- PRIVATE WELL
11. What type of wastewater system is on the parcel? SEWER PRIVATE SEPTIC
12. Do you need aseptic permit application? No Yes
MANUFACTURED HOME IN
FORMATION:
(INFORMATION FOUND ON THE PLATE OR STICKER LOCATED IN THE HOME):
Insignia serial#: CPF—ls 61)��2 fit,
Name of Manufacturer: y.R--iA L_ k'-6,K
Place approval#:
Model or component designation (New Home Only):
Date of manufacture: M R.P.,
Manufactured Home Application Revised January 2021
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): Jp5an P_ ar '
Mailing Address, C/S/Z: 45 Sand-rn, Rd, Que,.—,sKuru % il. kr��
Cell Phone: ?�[� )W i 5- 273P Land Line:
Email: yi Kinq-s2R, iera)_ omn*ka .cF ,
fM
• Primary Owner(s):
Name(s): , aciL-n +rirVL
Mailing Address,C/S/Z: L4,5 ctrtde i,� . i�5ittis_ ,� l NN INN
Cell Phone: ( i 8 Land Line:
Email: V; Ki;nnsH'iC
❑ Check if all work will be performed by the property owner only
• Contractor(s): (List all .dditional contractors on the back of this form)
Contact Name(s): Doyk
Contractor Trader c,. 04,c_ ire G Oo; a c
Mailing Address, C/S/Z: _ G�1�e%or VeV, P,J. n61 L180 V
Cell Phone: 5 .36(--Q q3i Land une:
Email: Cy—\-it. 'k- y6,,I7 Ann- Cs�XA
**Workers' Comp documentation must be submitted with this application**
Contact Person for Compliance in regards-to this project: 1)CkVA \L_"_A—
Cell Phone:�_) Land Line: �)
Email:
Manufactured Home Application Revised January 2021
A . .
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: r/",
SIGNATURE: DATE: /O-,ich-,
ZZ-
Manufactured Home Application Revised January 2021
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DECK OBE
308.11-1-73 RC-0774-2021 OCT 0 � 3
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45 Sanders Rd Bul�.D)!'T,,
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Install Footings
This chapter provides instructions for the design and construction of individual footings that transfer the load from a single pier
to the ground.A footing and pier together(discussed in Set the Home)is referred to as a"support'-A footing may also be de-
signed to carry the load of multiple piers(often called'strip'footings).The design of.strip footings is not covered in this manual. '
However,strip footings are acceptable if designed by a registered engineer or registered architect.The foundation systems
described in this manual have not been designed for flood resistance,
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�';STEP 1:=DES1G!`�I��)lN1''RflAQ�Stip�Oft`t'S(p:2t3)`
STEP 2.iiESlGttit FRa?,NlE'SUPPt1......i ie n litfi�ratPerimetec Blocking)(p..23)
V STEP 3,DESIGN,PF AtYiE 14ND:`OtRIMETEWSUPPORTSF(HoMes=Vltith Pedmeietr Blocking)`{p 25)
.._�: :;.:,.. �_,._":_�.;, � .-: . ,..•,._�e:-;:: .. Win,
V STEP 4:SELECT 06QTIN0,VATERIALS(p.
V STEP 5.SMEFOOTINGS.(p.31) `
_ter
V STEP 6.INSTALL FOOTINGS(p.33) V
STEP 1. DESIGN POINT LOAD SUPPORTS ,
All homes will need supports,and therefore footings,under the frame,marriage line(for
multi-section homes),exterior wall openings and other heavy point loads.
All pier locations required at the mating line,perimeter and any special pier support locations,
as required by these instructions,will be identified from the factory by a pier tag,label,paint,
or other means and must be visible after the home is installed.The pier designs,support
loads,and footing construction shall be as indicated in the appropriate diagrams,tables,and
instructions herein.Where perimeter piers are required along the exterior wall,alternate pier
spacing may be used in lieu of the factory identified locations provided the instructions of this
;x .
manual are satisfied in terms of allowable spacing,pier design,and footing size.
PLEASE NOTE:The manufacturer will not be responsible for damaged or removed pier tags.
It is the responsibility of the installer to ensure that all piers are properly positioned in accord-
ance with the tables&diagrams contained in these installation instructions.
Create a sketch of the home that includes the exterior walls,the frame 1-beams and then i
marriage line(s),if a multi-section home.The sketch will be used in this chapter to locate
each support,and note the size of the corresponding footing.Figure 6 is an example of
such a completed support plan. 3
PERIMETER f-DOOR PIERS '
BLOCKING PIERS
/-------I-BEAM FRAME '
i t Figure 6.T r <,�a_
MEMBERS 9 YP cal point-load
support locations
OPTIONAL= �Y
CORNER — _ _ _ MARRIAGE ref
'- --�- `r _ -�-- �' "--WALL PIERS
PIERS i
s f
FRAME PIERS
RC T 1-BEAM FRAME
\' I it I-BEAM FRAME
PORCH POST PIERS PERIMETER MEMBERS
j BLOCKING ;.
li PIERS
DOOR PIERS20
—j
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INSTALL NO. 3 1559 STATE OF NEWYORK 1 `—L"`' C
DEPARTMENT OF STATE
, ONE COMMERCE PLAZA
`; oA 99 WASHINGTON AVENUE
} {' ALBANY,NY 12231
g "' INSTALLER'S WARRANTY SEAL
THIS SEAL REMAINS THE PROPERTY OF THEi'DEPARTMENT OF STATE
t 1TH/
❑ NEW MANUFACTURED(HUD CODE) LOCATED MANUFACTURED(HUD CODE)
A. Manufacturer's name: \i' - _ C `f' C --- -
B. HUD label number: I ()Q to 4 l,9 — 0 t f n t'� Serial number: (1! r) Qt d 9,2.2,A. a 13
C. Retailer's name: At/d 4 —� . .,
• ' U`f r U t-.A) V\.
D. Retailer's address:
E. Retailer's certification##: Telephone#:
F. Installer's name: N : v I_-
G Installer's address: .?(J, , .. ' ,.1, ,,, t\A ( :,P, .,,,ch t, r 1f RO Y
H. Installer's certification#: 1 J��T l L`tin l Telephone#: 5/.�-3�n/-�, ? 1
I. Date installation completed: f i t T Municipality issuing building permit: { s,T > - .c >>,r tit
V (City,Town,r;V1Tlage)
— 1
J. Customer name and physical address(911)where home is installed: _ t►.qi n k..e1 V'\,+
s •r, f Q t� ( C), 1 0r ,NewYork.
By attaching this SEAL to this manufactured home,the undersigned Installer of this manufactured home warrants as follows:
1. That the installation of this manufactured home meets the standards of the New York State Uniform Fire Prevention and Building
Code.
2. That the Installer is certified as an installer by the New York State Department of State.-
The foregoing warranties are in addition to and not in derogation of all other rights and privileges which the consumer may have under any
other law or instrument.The foregoing warranties are in addition to,and not in limitation of or substitution for,any and all other
warranties,express or implied,given or made by the Installer,whether contractually or by operation of law.
Printed Name of Person Signing Seal: t : :;i i ;'_ \- i- "4---
Signature of Installer or ._
Limited Installer: __ r - 1
If you have a problem with your home,you should first contact your installer or retailer.If the problem is not resolved by the Installer or
Retailer you can contact the Department of State at(518)474-4073.
DOS-1680(Rev.06/18) -
Yellow Copy—Department of State White Copy—Retain for Your Records Goldenrod Copy—Permitting Agency Seal—Affix to Home