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2015-049
a In a � V N ICE CIA >• W W FGJ ~ lfl O z V pp � 6a O CC v LO N Q 00 cq Ln co rA z r o b 1� V) u Q r 4, W H A o ee C4 a 0.1 kn d" .�-� Vcq @ Lcn 41 5 ° U uo CO) ei ¢i CSA q Fuel Burning Appliance & Chimney p F' ti I a E ffice Use Only Received DATE: 3 LeD/S— MAR 1 1 2015 17a_Map ID TAX MAP ID: — � emit No. t7—049 1 TOWN OF QUEENSBURy Permit Fee 7r-)0 vadVd ZONE: BUILDING&CODES OWNER vecc ,sP .5s PHONE/E-MAIL 6---(�s_ 33s _9A I) ADDRESS 7 ? 0 c,A n©ot asoAs k 4.),P /0/7.04 INSTALLER/ (► PHO /E-MAIL BUILDER 5R l t CONTACT PERSON FOR BUILDING&CODE COMPLIANCE: PHONE/E-MAIL BUILDING ADDRESS ROOM OF INSTALL: PLANNED INSTALL DATE: ( n s- , FUEL BURNING APPLIANCE INFORMATION WOOD COAL PELLET GAS OIL NOTE: ROUGH-IN& STOVE FINAL INSPECTION ARE FIREPLACE INSERT REQUIRED. FIREPLACE,FACTORY BUILT* NOTE: MANUFACTURER'S FIREPLACE,MASONRY INSTALLATION MANUAL FURNACE(GARAGE ONLY) MUST BE AVAILABLE AT TIME OF INSPECTION *If factory built provide manufacturer name: ; Model #: Listed by: Number: CHIMNEY INFORMATION Masonry** (check one) BLOCK BRICK STONE Flue TIE STEEL Size in inches Material DOUBLE WALL X TRIPLE WALL X INSULATED ** If non-masonry provide manufacturer name: ; Model #: 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 inspector's to enter premises to perform required inspections. I HAVE READ AND AGREE TO THE ABOVE: PRINT NAME: J �� DATE: 3J / I iO10SIGNATURE: 7*-j: DATE: r//it a o/.S Town of Queensbury Building&Codes Principal Structure Application Revised September 2014 Town of Queensbury Fire Marshal 742 Bay Road "7 t" (aw Queensbury,NY 12804 761-8205/761-8206 fax 7454437 Factory Built Wood Burning Fireplace/Stove Inspection Report Notice: New York State requires that all UL Listed,factory built appliances he installed according to the instructions and specifications contained in the Installation Manual accompanying the appliance.No deviation from the manufacturer's instructions or specifications is allowed. U Permit# ti ()" Schedule Inspection 1 i Time I v am &�anytime Inspector Name �OS5� _Address �� n�{�( S7_ C-i \C Rough in Final Appliance Manufacturer Model#. Cc M l b„ 7 i Se:>C�) Masonry Chimney Factory Built Chimney & Flue Size Double Wa1L/<Triple Wall—Insulated____ Yes No NIA Comments Floor Protection X Clearances to Combustibles (all sides) X Safety Strip Installation (fireplaces only) Firestop(s) Vertical Chase Wall Penetration Chimney Clearances to Combustibles Chimney Termination 3 feet above roof penetration;2 feet above any combustible construction within 10 feet Combustion Air X Hearth Extension X Mantel(height above Up opening) Fireplace Doors 1 Screen (required) Carbon Monoxide Detection White—Building Dept. Mello —Cue mer Pink—Fire Marshal