RC-0337-2023 '
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• Office Use Only
MANUFACTURED HOME Permit#: -0351--ziD-2-3
PERMIT tIkQP�ll^ATION --Permit Fee:$ 3v 4 .00
Town ofC eensbury 742 Bay Road,Queensbury,NY 12804 IE l((�� L�2 O L/�/J
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P:518-761-8256 www.queensbury.net R-c Fee: $ L
JUN 14 2023 Invoice#: (vZI(o
73 Briwood Cir:Ie TOWN OF QUEENSBURY Flood Zone? Y N�Reviewed B J /
Project Location: BUILDING& CODES
Tax Map ID#: 0c-6. S Z
Name of Park(if applicable): Forest Park MHC, LLC
PROJECT INFORMATION:
1. Proposed Date of Placement: 07/01/2023
2. Approximate Value of Home:$ 50,000.00
3. Is the home NEW x or a REPLACEMENT ?
4. Single-wide or Double-wide ; Size: 16 ft.x 76 ft.= 1216 total square feet
5. Foundation support(choose one): Size Depth
x Piers: 24" 48"
Slab:
6. Is the home being placed on a private lot? No x Yes**
(**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: 2
8. Additional heat source? No x Yes Choose one, if yes: gas fp_ woodstove_ wood fp
9. Are there any other/existing buildings on the property? No x Yes ; Explain:
10. What is the water source? PUBLIC x PRIVATE WELL
11. What type of wastewater system is on the parcel? SEWER PRIVATE SEPTIC x —
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 #: TBD
Name of Manufacturer: Champion - Decatur
Place approval #:
Model or component designation (New Home Only): 1676H32P01
Date of manufacture:
Manufactured Home Application Revised January 2021
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CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): Forest Park MHC, LLC
Mailing Address, C/S/Z: 183 Pitcher Road Queensbury, NY 12804
Cell Phone: ( ) Land Line: ( 518 ) 745-7776
Email: forestpark@rhp.com
• Primary Owner(s):
Name(s): Forest Park MHC, LLC
Mailing Address, C/S/Z: 183 Pitcher Road Queensbury, NY 12804
Cell Phone: ( ) Land Line: ( 518 ) 745-7776
Email: forestpark@rhp.com
❑ 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): Dan Hunt/ Hunt Home Services
Contractor Trade: Site Prep/ Home Set Up
Mailing Address, C/S/Z: 36 Brickoven Rd. Queensbury, NY 12804 •
Cell Phone: ( 518 ) 361-2931 Land Line: (
Email: dirtywhiteboy970@yahoo.com
**Workers' Comp documentation must be submitted with this application**
Contact Person for Compliance in regards to this project: Tyler. Schrammel - Community Manager
Cell Phone: ( ) Land Line: ( 518 ) 745-7776
Email: forestpark@rhp.com
Manufactured Home Application Revised January 2021
1X4 JUN 21 2023
• TOWN OF QUEENSBURY
/i\ BUILDING &CODES
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BUILDING DEPARTMENT
u) Based on our limited examination,compliance
a) with our comments shall not be construed as
�. as indicating the plans and specifications are in
/) a) full compliance with the Building Codes of •
E New York State.
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