RC-0713-2023 Office Use Only
MANUFACTURED HOME Permit#:
PERMIT APPLICATION
�-- Permit Fee:$ Sigek
Town of CZuccnsbury
742 Bay Road,Queensbury,NY 12804
Rec Fee:$ M
P:518-761-8256 www.queensbury.net
Invoice#: b4'1\
Project Location: 10 Gregwood Circle Flood Zone? Y 6) Reviewed Bye-A/ 4-D
Tax Map ID#:
Forest ParkMHC, LLC O
(ifVE
applicable):
PP )
Name of Parka : l
NOV 0 6 2023
PROJECT INFORMATION:
11-3-23 TOWN OF OUEENSSURY
1. Proposed Date of Placement: BUILDING 8:COSDES
2. Approximate Value of Home:$50,000
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
❑✓ Piers:
24" 48"
❑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): 5 ;#of bedrooms: 3 .#of bathrooms: 2
8. Additional heat source? Non✓ Yes] I Choose one, if yes: gas fpn woodstove❑ wood fpn
9. Are there any other/existing buildings on the property? No V Yes ; Explain:
10. What is the water source? PUBLIC I✓I PRIVATE WELL
11. What type of wastewater system is on the parcel? SEWER I-1 PRIVATE SEPTIC
12. Do you need a septic permit application? No V Yes I (if yes, please submit separate septic application)
MANUFACTURED HOME INFORMATION:
(INFORMATION FOUND ON THE PLATE OR STICKER LOCATED IN THE HOME):
Insignia serial #:
Name of Manufacturer: Champion - Dectatur
Place approval #:
Model or component designation (New Home Only): 043000HA000323A
Date of manufacture:
Manufactured Home Application Revised July 2022
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**
K rt.
Contact Person for Compliance in regards to this project: TylerCL.liaidniniet
Cell Phone: ( ) Land Line: ( )518-745-7776
Email:forestpark@rhp.com
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 agre e above:
/
PRINT NAME: SCV' Pi/nle
SIGNATURE DATE: i ZGZ3
Manufactured Home Application Revised July 2022
e PROPERarrEcnca `TImcES' HOMESITE SURVEY LOtNon
" -Corner
,�e
„! t
Community Name: r G'(LPS+ PO4-4- ;LI Site#: CO (o
City Set Backs: Front Yard: g o Rear Yard (end to end): i Side Yard: /0 H -
Recommended Home Size: I CA• 1, Are Overhead Power Lines Present? / Yes n No
Considerations in Determining Home Size: I C S;Ze ck cc4-b`,u'
Source of Home Heating (check box): Natural Gas Propane Heating Oil Electricity
Please provide a Drawing in the center space above that indicates the elements listed below with measurements:
• Existing pad runners/ribbons or Piers • Existing driveway• Existing approach(walkway to home)
• Locate sewer,water,electrical • Indicate the location of natural gas hookup,propane tank or heating oil tank,if applicable.
Home 2}5.4 ' i.- + a Home
l Total Length of Site
Distance between homes (Distance from home to curb) Distance between homes
loa' .
Total feet between homes
� T
��, Addition, O t 6• �1 �;L �g4y aZG i Addition, laT
_-. Steps Steps =
or NA k Width of(dth
or Porch or NA br k: 2.
� of Porch )
sDepth of Porch. Depth of Porch g
en
C-
d:
—I Carport Carport
Yes or No Yes or No
x )C x . )(
size: size:
Distance from Distance from
curb to home 0 curb to home
Show loca ion of an _)O
overhead .ower line-,S
STREET (make measurement to back of curb)
Maximum Building Envelope Size: Width: 6) Length:
Name of person filling out this form:
e( Date: 4 3/0 c Oc bee2019
NEW YORK Department
• STATE OF
OPPORTUNITY_ of Health
KATHY HOCHUL JAMES.V. McDONALD, M.D., M.P.H. JOHANNE E. MORNE,..M.S.
Governor Commissioner Acting Executive Deputy Commissioner
October 4, 2023
Forest Park MHC, LLC
Attn: Joel Brown
31200 Northwestern Hwy
Farmington Hills, MI 48334
RE: Forest Park Mobile Home Court
Facility code: 56-6822
(T) Queensbury, Warren County
Install new manufactured homes on Lots 6 and 10 Gregwood Circle, 31 Briwood Circle
Dear Joel Brown:
We have this day, approved the plans for the above-referenced project. Application for this •
project was most recently received on September 29, 2023, and duly submitted by Tyler
Schrammel on form DOH-154 (Notice of Intent) that proposed to:
• Install a new 3-bedroom, 16-foot x 72-foot manufactured home on vacant Lot 6
Gregwood Circle, previously occupied by a 3-bedroom, 16-foot x 72-foot manufactured
home.
• Install a new 3-bedroom, 16-foot x 76-foot manufactured home on vacant Lot 10
Gregwood Circle, previously occupied by a 3-bedroom, 16-foot x 76-foot manufactured
home.
• Install a new 3-bedroom, 16-foot x 66-foot manufactured home on vacant Lot 31 Briwood
Circle, previously occupied by a 3-bedroom, 16-foot x 66-foot manufactured home.
The Department has no objection to the proposed action and the work may proceed conditioned
on the following:
1. Installation of the home must be compliant with the New York State Sanitary Code, Part
17, Mobile Home Parks.
2. The new home may not have a garbage grinder, whirlpool bath/spa, or any other high
usage fixtures.
3. If the onsite wastewater treatment system fails, the system must be brought into
compliance with current regulations.
4. Required separation distances from wastewater system components must be
maintained as per Table 2 in Appendix 75-A(Wastewater Treatment Standards—
Residential Onsite Systems):
https://www.health.nv.ciov/environmental/water/drinking/docs/appendix 75a.pdf
5. Approval must be granted by other agencies or municipalities having jurisdiction.
Glens Falls District Office,77 Mohican Street,Glens Falls,NY 12801,518-793-38931gfdo@health.ny.gov
6. Homes and accessory buildings or structures must be installed such that a minimum
separation distance of 10 feet exists between any home, building or structure on any
other site or parcel of land. If improper separation distances are observed in future
inspections, enforcement action will be taken.
Additionally, please note that this approval expires 1 year from the approval date.
Sincerely,
Brendan O'Connell
Engineer Trainee
NYSDOH - Glens Falls District Office
77 Mohican St.
Glens Falls, NY 12801
(518) 793-3893
Cc: Rebecca C. Bussed, District Director, Glens Falls District Office
Kevin Kenyon, P.E., Glens Falls District Office
Dan MacElrath, Glens Falls District Office
John O'Brien, Town of Queensbury
Tyler Schrammel, Community Manager
E -- - -----
° 308.14-1-52 RC-0713-2023
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