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RC-0518-2023 Office Use Only inn , , ., i MANUFACTURED HOME Permit#: eC. - 4r tb - Z823 \,�o ` - PERMIT APPLICATION Town ofQucensbury Permit Fee:$ ' 2. —' 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.queensbury.net Rec Fee:$ N\Pt - 'rot.4m..\\\ Invoice#: \'\ Flood Zone? Y Reviewed BProject Location: `V \S C\ -Nit, Tax Map ID#: 3 „\2_ L- Jc U Name of Park (if applicable): (1 � '� VL -4 UG 21 2023 I PROJECT INFORMATION: A 1. Proposed Date of Placement: (A I \ j , i ,l MAIN O C UEEN'BURY ' 2. Approximate Value of Home:$ \.5o (D �_,,,_,_,,,,,...,:� 1 3. Is the home NEW X or a REPLACEMENT ? 4. Single-wide or Double-wide X ; Size: 5kto ft.X O Z3 ft. = 1 p 5t- total square feet 5. Foundation support (choose one): Size Depth ❑Piers: \e'-8 OG Slab: %AD Ok . 6. Is the home being placed on a private lot? No Yes** X (**if yes,you must provide stamped engineered drawings of the permanent foundation plan) 7. Total#of rooms(exclude bathrooms): 5 ;#of bedrooms: 3 .#of bathrooms: a 8. Additional heat source? No❑ YeEt Choose one, if yes: gas fp'woodstove❑ wood fp❑ 9. Are there any other/existing buildings on the property? No I-1 Yes 4; Explain: O►`e,c_ 10. What is the water source? PUBLIC PRIVATE WELL.❑ 11. What type of wastewater system is on the parcel? SEWER ❑ PRIVATE SEPTIC 14 -x-\ ., C 12. Do you need a septic permit application? Nog] Yes❑(if yes, please submit separate septic application) MANUFACTURED HOME INFORMATION: (INFORMATION FOUND ON THE PLATE OR STICKER LOCATED IN THE HOME): Insignia serial #: 651 "I Name of Manufacturer: Place approval #: Model or component designation (New Home Only): is e \ CE-\---G.AiNc . Date of manufacture: 2oZ3 Manufactured Home Application Revised July 2022 t CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL tt • Applicant: Name(s): `c)t-kr) Mailing Address, C/S/Z: \Q> \v to4•0_ C �D� 12V-A Cell Phone: ( 5 S ) ` c�:� 0"1��-``� Land Line: ( -� Email: • PrimartiOwner(s): Name(s): f Mailing Address, C/S/Z: Cell Phone: ( ) Land Line: ( ) Email: ❑ Check if all work will be performed by the property owner only • Contractor(s): (List all additional contractor on th ack of this form) Contact Name(s): Contractor Trade: yk"\11a,tr\ So-'kto Mailing Address, C/S/Z: Cell Phone: ( .)5 ) 5 " \ Land Line: _ ( ) Email: (� CCC'-`tl� t rhb�eS . C( 1 **Workers' Comp documentation must be submitted with this application** L- t Sma=tl kr\v UT)VIN T\ . Contact Person for Compliance in regards to this project: Cell Phone: ( 5IS ) 5 a5 4S---- Land Line: ( ) Email: -_((-) - \ft) \k61`-e S 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: 06( GcAr) SIGNATURE: DATE: ql (? 1 if 9 7 l Manufactured Home Application Revised July 2022 - 1'8 w3 .�_ 1 I ' . -I TOWN OFIQUE' SBURY - -I _� _ ---1_, t • BULDING DEPA TME;T ; f 5ased on our limitec exams ation comp)ance -With o�r comments shall n t be- nstru d as ' ` ._ .. .... . • : .... .... . .... . ... .. . . . .. .. ... ndicat ng .the,plans and s ecific bons,are_in: -._, ;WI.co nplian se with the uildin Codes of FILE COPY York Stale. 1t 4 • 1----gc4f_7,6.-v )tt pp_cr<-3 is. , fs- O -e,ck 1 1s ' KSr0 u ,Sda ,-1. ,,. Vio" 0-e,C4 Cis'C' -e.� 4 1 p..... 1 � � r. l -- c . 3 .. i . d . �-- CoC8 VJ15Ct)n S i rt VEmE_ ,o26 -i ntea\cAn — Ak) .11,..4.14..s - ..11.‘ ;-e_ . , ti c t c X - (0 p .t S 4r-e I'D;. sir~, 0 00 ‘to /, &i a Q .,,94 ' (kt - Ili -1'.:--e._ ci, \KG\It...2,0‹,.. f-- Sfetr,' 3 �� 8b i �.. , /S �o .\C P 51- will . ej‘ °\S seVC4Cit ) . w....er o I36_0 f.,,.'v,!--' ', � S)(1.� t\(�N\t i t TOWN OF ; U r ._ d ' • BL I LD I N G & "O;t o ,1 -- :. 1 . Reviewed By: , v ��.�.- \ 0 ..._.,v_16-ti--iwGt L Date: / l0 3 2-` • .. ' ic:'r aPtt,) .6k C .A h\) I; . ' 4 ' (i5 0 • . t ... 1 I I ( cp-1201-1-7 S5 - - - 1 . . -11\EtWA4DVQC:*-:W:*lVu.i\v-IT ' . ,,,,f5u.4,- • , • I ' ------,1 ' . __. . v . . d 7 ! . 0 r , ,10'• _1 \ ''b c$ • : . \•PCY: . . . • ' t 0 ' . " . ' ( -4 D -1 . . I - fc6'' . • f--4--' \-- -...- , . • -- • i . . - .. ---1 ,:-- . . - • : . ._... ., . . _ . . . . ,. • . . . . .., . _ .. . _ ....._ • 1 , I cr , . . "I have-seerV:Or observed, or believe Raw evidence of, ..:, .all objects su h as.houses,'wells, treepences, etc.; '' - shown on t ...tio roent. I also repreAnt.that 1 have pe.rsonall 1C1.. s the Tstances set forth on the'diagrarn." 1,04a- --R( 6t(74;1 IC :7. SIGNATURE . . .DATE_ I v ; . . _ 0 l(\ ‘itA 1 Saitlatk 0 _______ c;:).11- Prn-ree-nz t Ai ;50,0_10:5i t.) 'WC:- iti..11: 1 I I I . i MFG. Champion Home Builders,Inc. DIVI: 019 951 Route 12 South COMFORT HEATING TN.maaaa..ad hen.Inn then bema9zh.4Yse b antra orb Os mn t. b oft.Weal maa bred ran. Sanperfield,NY,13455 m13r„nbo„ard Web Mandril l rdbongs*hU,v,b,Zen. 019-OOD-H-A006514AB N°�9° "" 'cif a Trill l� a i UNITSERp She graharn°prom*a'b•"P`fibm:�nan`maoa70'Fenwda•bn'm.roNmor , 1Iempeaa.,of F. CTN.2-20 HUDSEAL#PFS1318352,PFS1318353 To mzdnu..rnaa ope cm bmn.Tr atap. mry.edn eerily, recommended readed battle bone be InaredNre fa MODELqTadao ante dodo,emmahn(97%l)hnol highoM -"T Fahrenheit DATE OF MFG.BI752022 'DESIGN APPROVED BY PFS The gov''�Yn1r has been f`In.dessseripi madman*Ind moldal10WlI V grandam,arm�eioprem,a. 1 , .b, , ,norn1.1.,o.dbm,*.a.e.farellwetml w+Con„..on13,r�'o. aa+*^ COMFORT COOLING 1 ❑d.M.taa.• D Abe mndl*ma provided*famry(MmW.I) 1 OR ma,rngaad n.ew son ebrn sss mµan pt.oat*sE,Ed rarwr•n•d.1ma bs.rd N.rnsau AY nand***mauhrlrer aed=del(we/il Ten) b,mpu.r,ran!halal n ro Fe..bn b mdra ttode)n....m set.F.b,ilWJcand Nona cwa,aAan ones ..d.e,.gaaee0as Oq..Matbue9.oubn DrKbmM.MDlr.raar.m my CeM1dd neDaoq BTIAlwu b emdau rhh be eppd¢IAAY omM,wre' Cord*a,and Rehlperor,bead°Standards. ❑H.woadm,obampereerrrmd**aar.dbd„mern No...•••daamd.l mmlb+umn ThewdtldmMlwih9 q•bntmAOW bH.Iwro heaDesn zing Ewing ai Margo,aF. mixer.*be.ruhent mb*,kohcba 1M sadndbba b...dm..,b drTbgr ideated fad tech end)rt.lone facing Q hail,to cyst*,b dngrtd b , I •pia NDm M1r' mableb an indoor barpeabre al 7S•Fadan candor hmprdrn are .�dr zy/bob end_F OR net bib. 1 Manbm.YVV Mnng*nar,uW arum** 0.ed.•bda.rmda be'!rand a n.be.da®IYdLq 1 Tb tenperre brhih Ids hone�be condor Throe**NOV IV.M Trnevdolnpoan ol ' I r ITEMS MANUFACTURER MODEL NUMBER b.windows altNa haft loMe bra reradirr.me°toe'b°nomesheale'b`w"ydwd'b upon Me I r ' Furnace Nordyn. MG1E0)OFIABM2 borienhnnb be and micrma,N Norm pmsnd.Mongrel nab I i - eai dabon of mono bd savatMn datnr,rigors erasures end Magog re Po.'Nd b The I Water Heater ;i.e., E402R1195 I997 ASNRAE Handbook of Fundannbb.Inch-Pound Mon. Range wN*uPoe. WFG51550a52 - El M mnmuoner not provided a factory(Alternate) , Refrigerator .+aoaoa WR3315SOHM08 Washer is. AOburnsya.an cilia hone b arable ate Inatalan of corral i ard]orag Dryer Tu.supply adabbutmsystem Instated In Ws home ladesdfor a maaSatsd horn antal a ' Dishwasher 9100wuP011 WDF520PAOM9 cad.mnlnp gram olio to Omn BTUNT Wed r N widen ngel/d In accords.* Disposed Ai � g a Wed.038,rnchm ago *e•ter**babble Standsta,shen ohg*delving b Smoke Alarms FOR Alan 9,200 r 0051209N be manidectind Inre sr*ai duct*ran• _ FIlE OM TOUCKSTONE 800N Worst*rybmlmlY.mob9 nit Insa Imams dy, 8Fo,MedOR. Mar Microwave wale.POOL WMC3D516HZ0 son*crag 'M Waggon provided ❑ M mnddbNnp not recommended(Mange 18) I The doSt nneysbm ofwa home hos*limn designed Oam0oprorm olReoaes&central* • mNdAmrg olden. • INFORANEOIa PRWIOEO BY THE LONUFACTURER NECESSARY TO CALCULATE SEN0IBLE HEAT GAN Hose HOME CONSTRUCTION OZONE OZONE II ❑ZONEIII Wale(rThirs ._.—adonddoor.) _ "-'V Or hum hang ben bsbT.d b Fe higher gad prams err arsan9 pmdsbnarequid for member*Trees C.te,p erg Nola ofIV cob.._.... bcoo ad drug rialto bored rein WOO of be masers O WIncl2cone ad a,rho Me home and b eneanSo and 0.010 , bugaboo system have draped ed tor Increased eased rerre'+®5*scrod to Wog*D b ANWASCET ra et. CON admits oldaamb.__--__ ___.__ __._—V , TNs home ha❑ha col I been p 001e ❑ *oho* stag,Ter.or inch.none.bebhr,ad esbeb ibdn_._..—._______ V door N.•r,91 Fr homes de>✓Wdbb bMY,d Ores II tab Ol.Mom haw to eWen04 pa.ddeM 6HRe08 ershart ornery bdun b la am9y remnmendd Ina the brae be ehOe May b be equipped eft bite(*tub Ar&gin Ow.—___.._._. V Dam rmda*r.mRemand Normand*In mawaaavepiod imtuo5e.. N/A ' AY Aso In crib...._ V Structural Wind Zone mom AY Aab word maw tM hem if NH * , 41111111all©����� ��-W zosrz, µArab Ow__ _ 112 qe . "b'~Ni uAwbnearg o we VIIIIIICITalitrtglia'4A. �+•ETAk Asa oudd.MMro D �� I : _ _ d.pednlm _ To Whoa*h.windopacity ofpJpvnib cool atoA..eAUNy w.manicey a®►q bd(Inapabl 411�'Q9agarQ ubi.nergW.d,bmohgbdh trokltamkaimTrdb*winr41597 Iope.CrAYt I �� mr4NraNaopTrae amlehlrey Trd pl0,e,b pnestmoicctatTod rhn Mi apa3y�+aN spmb,�N M adolabd 2oNE1 /ram• ' Foda..005 Msibad EWNn,ore FMIKemn Id ewnbfm re born. rm Tb 1937 NaAooaol i IN .�T� / 20NEtZONEa UD Value Zone Map for Manufactured Housing i lh ER I :ONE] I Yr R, ❑zDNz■ erBallilitw" �1,� ; If checked;ANCHOR STRAPS MUST BE INSTALLED TO SECOND Ir.v %ea BEAM PER INSTALLATION ADDENDUM. � 4 ��1 w e Nn" uuaa l6el }. � a 1 g—EDErewIr / ., N h �waMMq 4W / ' ffi �L:® ' aI� ZONE r ©1:14F+L� NE 151. �i zaael • �zowu -0.0969 I • IjI r _ za ] -0.07 a.m. DESIGN ROOF LOADS ONE] . MEiATING I COOLING DESIGN MAP ❑ SOUTH 20 PSF pi.VALUE ZONES) NOTE 'The 30 PSF 'The manufacturer certifies this home Is compliant with the Title VI,Toxid H„rT,Pneroy�end%0. 0 NORTH 40 PSF Substances Control Act' Iaanmr50005ZaM ❑OTHER Psp srpacruRAL ROOF DESIGN IMP Ohr. 1 1 i INSTALL NO.3 A 2 2 7 STATE OF NEW YORK IDEPARTMENTOFSTATE 4 0/r. ONE COMMERCE PI AAA c3.* 99 WASHINGTON AVENUE ALBANY,NY 12231 _^MANUFACTURER'S WARRANTY SEAL j �— STRUCTURAL - ---- p oritaa -- —Substances CbliliiilAct^ ROOF DESIGN MAR ONO INSTALLNO.3E� I 227 STATE OF NEW YORK DEPARTMENT OF STATE 1 , >� :+ ONE COMMERCE PLAZA QA. 99 WASHINGTON AVENUE ALBANY,NY 12231 MANUFACTURER'S WARRANTY SEAL THIS SEALREMAINSTHE PROPERTY OF THE DEPARTMENT'OFSTATE By attaching this SEAL to this manufactured home,the undersigned Manufacturer of the manufactured home warrants as follows: 1. That this manufactured home is free from any substantial defects in materials or workmanship. 2. That the Manufacturer,or the retailer for the account of the Manufacturer,shall take appropriate corrective action in instances of substantial defects in materials or workmanship,which become evident within one year from the date of the delivery of this manufactured home to the consumer,provided the consumer or his transferee gives written notice of such defects to the Manufacturer or retailer at their business address not later than one year and ten days after date of delivery.Such appropriate corrective action will be taken at the site of this manufactured home,and within sixty days of receipt by the Manufacturer or retailer of such written notice. 3. That the Manufacturer is approved to construct manufactured homes by the United States Department of Housing and Urban Development. 4. That this manufactured home was constructed in accordance with all applicable federal,state,and local statutes,laws,codes,rules, and regulations. 5. That the Manufacturer is certified as a manufacturer 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 Manufacturer,I whetherp contractually or by operation of law. Man n p Name of Manufacturer: (.)lnn7DI.n l 'fDntL Dtt,Icic('_`, Tt}c.Manufacturer's Certification#:?l�)ANOi ? 1 HUD F r_`')jl�'35c2 FF5)31,31353 019-QM-N-Rf!?i�G.51LIR8 Serial Number. Printed Name of Person Signing Seal: h rn /"!n ;, .r• ii Signature of Manufacturer or J� r / J 1\ Limited Manufacturer. L/ (/t/ }/ v If after contacting both the retailer and manufacturer concerning potential defects in your home,and these defects remain unresolved, , +4 you may contact the Department of State at(518)474-4073. 1 i i Doamai(Roo.ocvsl 1 I Yellow Copy-NYS Department of State White Copy—Retaln for Your Records Seal—AMA to Homo f 1 i4j j LUP )Vr ROAD LANDS OF �828' nVE MAIN STREET QUEENSBURY, LLC L. L. 5176 P. 19.3 LANDS OF JMES CONDON, 47. & AUDREY CONDON FENCE L. 45;'2 P. 1,30 100 .00 4 M PAVED I STY C V CZi-\V FRA DRIVE ME �o Clot "lVr,S OF, BLOCK --N_.--GARAGE PHILLIP Y. PFKAR --P ri 0 CLEAR L. 4377 P. 269 -k I �A ----j N V &V of W CH 10aoo T?,-XARACLEA,0 �E .2' 49 v /8 GARAGE CLEAR RONALD K. ALECIA L. NAA 7Z LANOS OF LANDS OF L 4 741 P. 77 CHANDLER BROTHERS THERS U C L. 503J P. 12 to rt; LE FOUND IRON MARKER SET IRON ROD W 774 CAP 0 POINT POWER LINE — NONE WALL L — x — x - FENCE ONLY COPIES FROM THE ORIGINAL OF THIS SURVEY MARKED W774 AN ORIGINAL OF THE LAND SURVEY EMBOSSED SEAL OR INKED STAMP SHALL BE CONSIDER0 TO BE VALID TRUE COPIES MAP REFERENCES.- 1. MAP OF WESTERN PARK BY EH KUS DATED JULY 1927 AND RLE IN THE WARREN COUNTY CLERK'S OFRCE IN BOOK 2 PAGE 58 2. TAX MAP JOB. 12-2--3,15 DEED REFERENCE:' L. 51 P 52 VIT'd. kjm��#� TO ON OF QUEENSBUR Y.. SCALE: I - 20x 0 Unauthorized Alteration to this map is a violation of Section 7209, Subdivision 2 4 of the New York State Education Low. V V0. 4140 -198 L --------- - 1101 WARREN COUNTY, DAM- JAN. 15, UPOA TED iAN, 22,2019 FILE copy py 308.12-2-35 RC-0518-2023 Nolan, Deborah 68 Wisonsin Ave New Manufactured Home 1568 s.f. NEW YORK FILE' 118116-054116-54.DW,- IN TOWN OF QU BUILDING &I Reviewed B TOWN OF QUEENSBURY Date: BUILDING DEPARTMENT Based on our limiied;,:,�xarm,titian, compliance — + with our cornrnen' fi snecilica ions are in full Compliance W1 h e building Codes of New York State. STOCKADE FENCE S 8#*,T7000'* IE lcaowo dam Am _V 10 =7 0� "q� '.1 n Q 7-7-_77 r PA IVE9 ,O RVE + WK)II)i V IVOIUI.Daizl .0.x iC) VNiGiNnId &OCK F PA 77C, Ac- Z,A R A c7E C L rr__ A P 1A1ff�WmmL_m1mVmL;a nio Az Az -co Z 4r-,, E 6' " m dD E y oct N o W �. r.::::i N 0; Z _ h Z ~ M O 1 O N�' OD E Z OD n O O I M .0 a:= O N E �........W -0 N i W a, a Z d u) :3 Q H Q N m v a N w� C L U d ® O C C W f- N H W Z � r E .. n y G R o n (60, O c� z E N o w 0 o Z �- > N y y Z w C N 15 a Q 0 0 CU a y i m Lu - kL RF C O 0) C N J •a W ? 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E w to -5 - 'o L LL < ca 0 < L U --fA 3 P-mawn Ills 01 0 f:uiewnNINE[WNOISS'�, .=N lN3WN!DISSV inew -IdOlneluisia 16 1 N,.IN 0 MV-82TON(7/22) PAGE 1 OF 2 Department es APPLICATION FOR TITLE I IIIIIIII II IIIII(IIIII IIIII IIIIIII IIIII IIIII II(III PLEASE PRINT WITH BLUE OR BLACK INK .... . IMPORTANT— DO NOT USE THIS FORM TO REGISTER A VEHICLE, BOAT OR TRAILER " """FOR OFFICE USE ONLY Please carefully READ THE INFORMATION ON PAGE 2 of this form. Batch File No. Proof Submitted NE^tw OWNERS i S1 NAtmt ORCOMP�..� iO4STwt~NA M1. mm IC Iw O.ffrv"u DIN IV,t"Lrn t TE OF:SLIM, SEX Month Day Year M F X ❑ ❑ ❑ 2 NEW C04DWNER S LAST NAME FIRST NAME------ -------------------- . 'J F-1 M F. ID Ram Drlverticense4 DATE OF SIM SEX = I IMonth Day Day I� Year M F X ❑ ❑ ❑ Hndud�. »»�. � CITY OR TOWN STATE ZIP CODE C(WNTY e�StreetNumrEWS �antlName�uralDelrer^iandlorBaxNum6er Cl,. ����_...... _...... _ ...........�� ------- .-------- _.............» ADDRESS WHERE YOU LIVE—IF DIFFERENT FROM YOUR MAILING ADDRESS— DO NOT GNEPO BOX_(Include Street Number and Name) _ CITY OR TOWN _ _ STATE ZIP C CODE COUNt"t... _mmm...m_mmmmmm ._...,..�.._... ��. ...�.....m _ ... ......_..... �_�._m.�.__.�. ......�.� Apt.No. � »..,,,, ,,,,, ..w..,..�, ,.. .............�,,. W.,.,....... ....... ....��_M .._��._....... 3 COMPLETE ONE OF THE FOLLOWING:*OR(E)i OR OR VEHICLES AND MOTORCYCLES BOATS O � »[q, %� NLY Haw was the boat obtained? ❑New ❑Used ❑Leased �MMJLEAGE ASRt tJSFQNlY ❑SalvageUs vehicl❑LeasedHow was HULL IDENTIFICATION NUMBER BRAND ��❑New�❑Used ❑Lease'Buyout VEHICLE IDENTIFICATION NUMBER YEAR MAKE LENGTH Feet Inches p YEAR MAKE COLOR ODOMETER READING IN MILES v HULL MATERIAL ❑ Steel ❑Other ❑ Wood ❑ Plastic ❑ Inflatable ❑ Fiberglass ❑ Aluminum VEHICLE TYPE * _ �,,!i ,l. . Other .__....�..�.�.�. _...uu_�_....��. m for how [10 2 Door ❑4 Door (DO NOT INCLUDE TENTHS.) numbers?❑ PROPULSION IT ITITIT --- Co ,,, , nvertible ❑MotorcycleTYPE OF .. ...Ot r � oard ❑ Sail Van ❑ Gas ❑ Diesel ❑ Electric Truck(List Type) ❑ Flex ❑ CNG ❑ Propane CYLJNDERS ❑O aheboardmmTym�...❑ nboard -� ❑ n oar ut — ❑Pick up ❑Dump ❑ None❑ Other ......m F IFL ..... ❑Fire ❑Tow ❑Utility MAXIMUM GROSS WEIGHT ❑Other Type of Vehicle or UNLADEN WEIGHT (FOR TRUCKS) LO Gas ❑Diesel ❑Electric ❑None ❑Other Truck(explain) LE3 Less than 16,000lbs. 16,0001bs.or more ._�. ADULT SEATING CAPACITY GF$ IL " N 49rc�e�rr ti r lTwe tR ti#Mtr i9tiM i9ir C91 ,,,o 0_ ww.�_�.1 Leased ❑Salvage (Including Drlver) Is the vehicle currently registered it Yes,Plate Number. ❑New ❑Used ❑ in new owner's name? VEHICLE IDENTIFICATION NUMBER 0 Ves O No © MANUFACTURED HOMES ONLY How was the manufactured _............ _..... ..................... home obtained? NI New ❑Used YEAR MAKE COLOR UNLADEN WEIGHT SERIAL NUMBER 0 1 1 9 ffOO 0 JH JA 0 0 6 5 1 4 A B —m-min ❑Yes ❑ N W. _.. lered TYPE m new owners names Is the treiler cunently regis YEAR MAKE COLOR SIZE o ❑House Trailer ❑Boat Trailer 2023 LHA�PION HOMES width Length HYes,PlateNumber. ❑Semi Trailer ❑Refrigerator Trailer ........ .. ...._........._.�._.. �M.�,...,,».. 2 S 5 6 ❑Other,..—. ... .. i',4 Choose one ❑ There are M liens. ❑ I am filing for the lienholder(s)listed below. Lien Finn Code Lienholder Name Lienholder Malim Address(number,street d state,zq i coder ��..._.._.����� � �,.... ,.._.,__ ..�_. ........_.�......._._�....... �Stgnature(s)required on back —J� NEW OWNER'S LAST NAME FIRST NAME L� PAGE 2 OF 2 nnv azTON(��zz) DAMAGE DISCLOSURE-must be completed for vehicles,motorcycles and trailers I certify that,to the best of my knowledge,this vehicle,motorcycle or trailer 0 has been or 0 has not been wrecked,destroyed or damaged to such an extent that the total estimate,or actual cost,of parts and labor to rebuild or reconstruct the vehicle to the condition it was in before an accident, and for legal operation on the road or highways,is more than 75%of the retail value of the vehicle at the time of loss.(Checking the"has been"box means the vehicle must have an anti-theft examination before being registered,and that the title issued will have the statement"Rebuilt Salvage: NY"on it if the roof of ownershi is a New York State title.If the roof of ownershi)is an out-of-state title,it will show that state's abbreviation.) OWNER CERTIFICATION: i state that the information I have given is true to the best of my knowledge.If the vehicle,motorcycle,trailer or boat is currently registered in another name,I authorize such registration.if there is a co-owner,BOTH signatures are required. 1. New owner Sign Name in Full Date Daytime Telephone Number ,.,.Print Name.`_.__ n Full 2. .�.�. _n__.. —Full ­'—'------- �... __._.. _....._._._... ) New is o c caner Sign Name in Full IDate Daytime Telephone Number If signing for a corporation,print your name and title X... 7® MANUFACTURED HOME DEALER •RTIFICATION: I certify that all New York State and local taxes due as a result of this sale,if any,have _ � the p user.been collect 673 16 1504326 X nature I,eater or Authorized Re 6 rI ✓ i�,� r sentative. . ....._ .. .12..4 12 0 2 3 _._. ( 518 8 ele hone Number...... 9 p NYS Sales Tax Number Certificates of Title are available only for the following% ♦ 1973 and newer model year vehicles and motorcycles(including salvage vehicles). ♦ 1973 and newer model year trailers with an unladen weight of 1,000 lbs.or more. ♦ 1987 and newer model year non-documented boats that are at least 14 feet long and equipped with a motor. ♦ 1995 and newer model year manufactured homes that are at least 8 feet wide or 40 feet long when being transported,or at least 320 square feet when erected on a site. THIS IS WHAT YOU NEED TO APPLY FOR A CERTIFICATE OF TITLE. I ,fi?fG,K7ATJ0N(l�R 1�1.A1�-BATON)-After completing appropriate sections as outlined on top of page 1,please make sure you sign the owner certification in Section 6 and the dealer signs Section 7,if applicable. 2. PRtF UC ttv�"1\lIK$Ii1P-Ifpurchased new,the proof of ownershtya is a ufanufacturer' Safetnent or Crtificte ofC)rigi .IfpuTchased used,the proof of ownership is usually a certificate of title(or a transferable registration and bill of sale if from a state that does not require a title).For vehicles, motorcycles,and trailers sold by a New York State dealer,a Certificate of Sale(form MV-50)is also required.For boats sold by a dealer,a bill of sale from the dealer must accompany the proof of ownership.If you have other proof of ownership,please contact the Title Bureau to find out if it is acceptable. 3. ,PO.OF,,OF NAME AND DATE)F BIRTI?-Cooly proofs of name that contain the owner's signature will be accepted.For example:a copy of a photo � driver license,a military photo ID card,or a credit card.Proof of date of birth is a copy of a.photo driver license,a birth certificate,or military separation papers(DD-214).A corporation must provide proof of incorporation. 4. SALES TAX CLEARANCE-Proof that you paid or are exempt from paying sales tax is needed.The following are acceptable proofs of sales tax clearance: ♦ Form MV-50(Certificate of Sale)-for vehicles,motorcycles,and trailers purchased from a New York State-registered dealer. ♦ Form FS-6T(Sales Tax Clearance Receipt)-for vehicles,motorcycles,trailers and boats purchased from an out-of--state dealer,or through a sale that does not involve a dealer.Form FS-6T may be obtained at any Motor Vehicles office by paying sales tax or by showing that you are tax exempt. A bill of sale-for boats purchased from a New York State-registered boat dealer.The bill of sale must indicate that tax was paid,or that the purchaser is exempt from sales tax. ♦ Signed Manufactured Home Dealer Certification(Section 7)-for manufactured homes purchased from a dealer authorized to collect New York State and local sales tax.The Manufactured Home Dealer Certification below must be completed by the dealer.PLEASE NOTE:Sales tax clearance is only required for manufactured homes purchased as NEW. 5. FILING LIENS-Section 4 on page 1 can only be used by a dealer to file a new lien.All other liens must be recorded by the lender sending a Notice of Lien(form MV-900)and$5 lien fee OR form MV-900.1(if they have an account with the Department of Motor Vehicles).To be sure the lien is recorded before the title is issued,the lender should send the Notice of Lien with this application,OR as soon as possible after the loan is made(these forms should not be given to a customer to mail in).For further information,obtain our pamphlet"What Lenders Should Know About the NYS Vehicle and Boat Title Program"(form MV-909)by contacting the Motor Vehicles Title Bureau,or by visiting our website(dmv.ny.gov)under Forms. 6. T TLD'LIEN FEE-The fee for a title for all vehicles,motorcycles,trailers and boats is$50.Th' tE e'Tvr'a Certificate of Title fot a inanitiactuted'h, The fee for filing a lien is$5.Payment must be made by check or money order payable fd`Coreunissigtter of Motor Vchle PLEASE NOTE:We can only accept payment of the lien fee from a dealer or lienholder.The lien fee cannot be paid by the owner. 7. Bring your completed application to any DMV office,or mail to the address below,with: ♦ proof of ownership ♦ title application fee ♦ proof of name and date of birth ♦ notice of lien and lien fee(if applicable) ♦ sales tax clearance(if applicable) ♦ proof of Power of Attorney(if applicable) Mailing Address:'1ItIa`Bureau Department;of Mi .B otor Vehicles, ,Empire State'Plaza;Albany,NY 12225" 8. The following applications must be mailed to Title Bureau: ♦Garageperson Liens ♦Salvage Certificates ♦'Mauufactured-316ines ♦Boats ♦Bonded Vehicles ♦Application by Dealer/Manufacturers for vehicles returned by purchaser under Lemon Law Visit us on the web at:dmv.ny.gov LE5ET / CLEAR