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2025-0008
FUEL BURNING APPLIANCE & Office Use Only CHIMNEY APPLICATION Permit#: Z0ZS — 000 r 1.7 (..- : n wi. .Tif r., Permit Fee:$ a 7 S/0 l/ Town of Qucensbury 11 742 Bay Road, Queensbury, NY 12804 Invoice •' \ P: 518-761-8256 www.queensbury.net JA 06 2 -, TOWN OF QUEEWSI3URY **ONE A PPLI:CAIIO:N RER�FAA.PI_ NCE** • Project Location: '1 Qu ffu CrOdij SA. Tax Map ID#: 30q(• /7 - - J -I Room of Install: U i Kj1 1 000 1fr, Planned Install Date: 1-31 1015 FUEL BURNING APPLIANCE INFORMATION: TYPE OF DEVICE: ' ©Stove ❑Fireplace Insert n Fireplace Fuel Fired Equipment (Garage Only: 18" clearance per IMC 304.3) Fireplace,factory built** (**Manufacturer's name: O,b(e4 "CH jC`ejlOc_ Model #: 1013041gd0 ) SOURCE OF HEAT: f 1 Wood ❑Coal ❑Pellet ❑Gas CHIMNEY INFORMATION: Masonry(require plans to be submitted): 0 block El brick ❑stone n Flue: ❑tile ❑steel assize, in inches Material*: . ®double-wall E triple-wall ninsulated • (*Manufacturer's name: dJ-rCLVC.f+ Model#: ) Fuel Burning Appliance&Chimney Application Revised December 2020 CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL • Applicant: Name(s): f)o b a L. 1C,7f7 Mailing Address, C/S/Z: `� 01.4.cicrti Cr'o5s(f� �_ Cell Phone: ( rt'? ) ,Y9`l—5j( Land Line: ( Email: flk J. yc,h,Q.ro�'r' • Primary Owner(s): Name(s): j/46/$ca. L.arn • Mailing Address, C/S/Z: ►7 hr i- - Cr 0551 tq s - Cell Phone:_($t ' ) 'O r(ov3 Land Line: _( Email: /atr4hcr-Too., 7citei1 v iria r/ ,Corr] ►_1..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): Contractor Trade: Mailing Address, C/S/Z: Cell Phone:_( ) Land Line: _( Email: Contact Person for any questions regarding this project: Zjet Cell Phone: (/118 ) ?11 `S't/' Land Line: ( ) Email: ItiP flag .Com 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: rG 1GcS L. NO _4142_,LL SIGNATURE: • / /- DATE: Fuel Burning Appliance&Chimney Application Revised December 2020 . 1 ! 1 ! : , : ! ! . ! - Iill : ! ! 1 [ 11 . iL ! • Iiilmi ! , : . i -, --:----f-----.)--! ---1-- , -r.,--, --;-- i . ry,-.1 '4,,,,,i . , 41 ., . • •11 11 , 111111 ii ! hi . i 1___I _q_kviAttote......t_Y. 1 . ., %,,:.:...Li..-_,...:_•_i..t._!....:..,',..___ _ • , , i - 1 , 1 • , .! . ' .1.-.-1 1--• i• -. ;- :- ••••i - •-•i• - -1- r • i i Li), 1 .0 \II i 1 I i I • ! i ! i 1 I 1 ! III I il ! :__•--I----i______I---I- _•--I-- •!--:----,---kmAke,u1.9-0-Pti' W " h! 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