2024-0136 r'
S ,r� FUEL BURNING APPLIANCE & Office Use Only
14 ) CHIMNEY APPLICATION Permit#: 2O24 —01510
� Q Permit Fee:$ "J%
Town of Quecnsbury (_ef.�\
Invoice#: ,
742 Bay Road, Queensbury, NY 12804
P: 518-761-8256 www.queensbury.net
**ONE APPLICATION PER APPLIANCE**
Project Location: 5 -N.-ear-Awl Rd Tax Map ID#:
Qi.,wfa_rt.sk-t I N-j IZEoc/
Room of Install: Livi v1o, f oovi i Planned Install Date: no i,►'')5 ,\1
i
FUEL BURNING APPLIANCE INFORMATION:
TYPE OF DEVICE: -.et(e--I- stov-e, 1inSeri—
Stove X Fireplace Insert _ Fireplace
_ Fuel Fired Equipment (Garage Only: 18" clearance per IMC 304.3) •
Fireplace,factory built**
(**Manufacturer's name: liarma_fi Model#: h ri - )
521 - IL
SOURCE OF HEAT:
OX Wood _Coal ,( Pellet _Gas
CHIMNEY INFORMATION: I//ij
Masonry (require plans to be submitted): I AR 21 11
block _brick _stone ! FG[� .�; -=-
'tee.„ J-`J r{ 'j -:`1,tK_r '
'V Flue: ` i
tile steel _size, in inches
Material*:
double-wall _triple-wall_insulated
(*Manufacturer's name: 40.r 0--(1 Model #: )
Fuel Burning Appliance&Chimney Application Revised December 2020
'� CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): _
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: ( )
Email:
• Primary Owner(!):
Name(s): l r k_ tiU-e i cl-(1 -r oG 1\1\c,-_ ,,� ram. "M c_eQ ✓ °c
Mailing Address, C/S/Z: 5 R.-ecA.-4_6 1� 13 U,s2_0--n.SAOL.L , A- -7 l 2$oy
Cell Phone: _( 5 I'S ) g 3 -3,3l ' Land Line: _( o—)
Email: ( yyyx Ck-e rl�i e, (0 1 a oma: 1, co iv
❑ Check if all work will be performed by property owner only
• Installer/Builder: Workers' Comp documentation must be submitted with this application
Contact Name(s): 1-k R,-(2._c_,)Ino (c(S GVO -
Contractor Trade: �(1.0- S V-e_S
Mailing Address, C/t/Z: " 1 5 4 I Ni --6 `7 S ck 1-f t c� EQ Al lal s'
� s J �
r,Cell Phone: (5( g ) -7 5 3 - -3y r,0 Land Line: ( )
Email: _ v..o l s e rnot_ C . Conte
Contact Person for any questions regarding this project: ((\/\a-14-- R_��_ I JS
Cell Phone: ' ( ) Land Line: ( )
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. Masonry fireplaces & chimneys require plans to be submitted.
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: Ni\d" u'1'+`-Q-' Ma `e V}-1-C_.
SIGNATURE: C-43/40 ,,,Q DATE: ./6 I Z 2 1 L44
Fuel Burning Appliance&Chimney Application Revised December 2020
1111111611___Pit
FIRE MARSHAL'S OFFICE
Town of Queensbury
AN 742. , NY 12804 Bay Road, Queensbury,
"Home of Natural Beauty ... A Good Place to Live "
PLAN REVIEW
MacKenzie, Maryanne
5 Reardon Rd
2024-0136
Pellet Stove Insert
3/26/2024
I have reviewed the submitted application for the above project; and offer the
following comments:
1) Install pellet stove insert in accordance with manufacturer's installation
instructions and recommendations, including but not limited to clearances,
etc.
2) Contact the office to schedule the required inspections for rough-in and
final, including witnessing the operation of the unit
3) Have pellet stove insert specification booklet available on-site at time of
inspection(s)
4) CO detection to be required
f.•/7
Deputy Fire Marshal
John Schadwill
742 Bay Road
Queensbury NY 12804
518.761.8206
schadwillj@queensbury.net
Fire Marshal's Office • Phone: 518-761-8206 • Fax: 518-745-4437
firemarshal@queensbury.net • www.queensbury.net