FMP-0741-2021 % ' FUEL BURNING APPLIANCE & Office Use Only
CHIMNEY APPLICATION Permit#: FW1R ~ O`41 " 202(
Permit Fee:$
Town of Queeres6uty
742 Bay Road,Queensbury,"NY 12804 Invoice#: 4Z.1'O
P: 518-7 61-82 56 .www.queensbury.net
**ONE APPLICATION PER APPLIANCE**
Project Location: Z"? Ali o►k LI.4 t 0 r- Tax Map ID#: 3o) . I S 'Z r ,
Room of Install: 0en Planned Install Date: L-/- Z b2-/
IECEllv 12
FUEL BURNING APPLIANCE INFORMATION: OCT 0 J
2021 0
TYPE OF DEVICE: TOWN
BUILDING& NSBURy
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I
'•" Stove .. '"- Fireplace Insert Fireplace CODES
Fuel Fired Equipment (Garage Only: 18" clearance per IMC 304.3)
Fireplace,factory.built** --
4 ..
(**Manufacturer's name: 13 )it %e k-rF Model#: p r i was s Zc )
SOURCE OF HEAT:
XWood _Coal _Pellet _Gas
CHIMNEY INFORMATION:
Masonry(require plans to be submitted):
block brick stone
? Flue: '
atile. steel _size, in inches
Material*:
"' 'double-wall _ triple-wall^insulated "
(*Manufacturer's name: _ Model-#: )
Fuel.Burning Appliance&Chimney Application Revised December 2020
, .
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): . . . _ . .
_ _
vailirt Address, C/S/?: Adj-a at-7 tea
Cell PhbriO: ( 512 . ) W 72 7 'Z- -'ttand Line )
Erriil
-- -6' Primary Owner(s): - - • --
-Name(s): . • •
Mailing Address, C/S/Z: .
Cell Phone: ( Land Line: (- )
Email:
reheck WaD Ikork•will-be performed.by proporty,owner Only.
• Installer/Builder: Workers' Comp documentation must be submitted with this application
Contact Name(s): • •
Contractor Trade:
Mailing Address, C/S/Z: - - - • —
Cell Phone: ( . _) Land Line: ( )
Emdil: ''
. .
Contact Person forany-questions-regardingthis-projeg:Fm7-::: -------
Cell Phone: (
Email:
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,—Masenry-fireplaces-&-chirrireys-rec-.:uire
4. Twenty-four(24) hour notification is required for inspections.
5. 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: 5 ;
SIGNATURE: gelL"---A\ DATE: I
Fuel Burning Appliance&Chimney Application Revised December 2020