RC-000205-2016 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5904 (518)761-8201
Community Development - Building & Codes (518) 761-8256
CERTIFICATE OF OCCUPANCY
Permit Number: RC-000205-2016 Date Issued: Friday, May 27, 2016
This is to certify that work requested to be done as shown by Permit Number RC-000205-2016
has been completed.
Tax Map Number: 309.9-2-1
Location: 200 LUZERNE RD
Owner: AGL Homes
Applicant: Robert Lawrence
This structure may be occupied as a: 980 s.f. Mobile Home
Lot 97 Alpine Ave. By Order of Town Board
TOWN OF QUEEENSBURY
Issuance of this Certificate of Occupancy DOES NOT relieve the T/ J
property owner of the responsibility for compliance with Site Plan, GGGwwwsss���
Variance, or other issues and conditions as a result of approvals by the Director of Building&Code Enforcement
Planning Board or Zoning Board of Appeals.
TOWN OF QUEEN BURY
742 Bay Road, Queensbury,NY 12804-5904 (518)761-8201
�n
Community Development - Building; & Codes (518) 761-8256
BUILDING PERMIT
Permit Number RC-000205-2016
Tax Map No: 309.9-2-1
Pennission is hereby granted to: Homestead Village
For property located at: 200 LUZERNE RD
In the Town of Queensbury,to construct or place at the above location in accordance with application together
with plot plans and other infonnation hereto filed and approved and in compliance with the NYS Uniform
Building Codes and the Queensbury Zoning Ordinance
Type of Construction
Owner Name: Rick McGrain Mobile Home $28,000.00
Owner Address: 4305 State Route 5 Total Value $28,000.00
Caledonia,NY 14423
Contractor or Builder's Name/Address Electrical Inspection Agency
AGL Homes
4305 State Route 5
Caledonia,NY 14423
Plans&Specifications
980 s.f.Mobile Home
Lot 97 Alpine Ave.
117.60 PERMIT FEE PAID -THIS PERMIT EXPIRES: Monday,April 10, 2017
(Ifa longer period is required,an application for an extension must be made to the code Enforcement Officer
of the Town of Queensbury before the expiration date.)
Dated at the Town sb , Fri 5, 2016
SIGNED BY: for the Town of Queensbury.
Director of Building&Code Enforcement
MOBILE HOME APPLICATION Office Use Only
Deceived
DATE - /' 3 `r Tax Map ID
�
TAx MAP ID , Permit No.
PROPERTY t.ocAnoN•
NAME C}I=1� OBILE HOME PARK: ���� � � � �� � w�
PROPOSED DATE OF PLACEMENT: " /'r
BUILDNG& CODES
A.PPUCAnrr I .
OrnrE
ADDRESS I"k ADDRESS �y i
PHONE (MO,s 1 PHONE
NAME OF INSTALLER OR MOBILE I"omE DEALER
ADDRESS: .,
I Y
PHONE - Cl
iCOW7ACT PERSON EOp4 - ILDING'r'&ICODiES COMEL/ANCI" � �L t W"► PHONE:
COMPLETE INFORMATION BELOW FOUND ON A"PLATE'OR"STICKER"VWHI H IS AFFIXED TO THE MOBILE HOME
Insignia serial number
Name of Manufacturer A�Y y l
Place Approval plumber
Model or Component Designation - S40 '717- (New home only)
Date of Manufacture:
MOBILE HOME INFORMATION ZONING INFORMATION
Approximate Value of Herne $ Zoning
New Home or Replacement
� Size of property ft.by
Size of Mobile Horne ff.by ft. Existing buildings �
Singlewide or Doublewide �" Accessory buildings
Number of rooms(exclude bath) Storage buildings /10410-1
Number of Bedrooms Detached Garage 1 —2 —3
Number of Bathrooms Attached Garage —1 _2 —3
Das Fireplace;Wbodstove or Wood Fireplace Setbacks Front yard: ft.
6 Bear yard: 1-5- ft.
Side yard: -/_0 ft.
Foundation Support Size Depth Water Supply Well:
Piers Municipal:
Runners
Slab Septic Permit Required'? `'yea —"o
Town of Queensbury Building&Codes Mobile Home Application July 2014
Procedure for placing and occupying a mobile home or modular home:
1. Application is,submitted and review: 2 copies of plot plan and layout must accompany application along with
septic application (if needed) and fee.
2. Permit is issued– Permit carol,is,placed on property
S. Footing forms are inspected before pouring concrete: Home is placed on foundation or piers
4. Arrange for electrical inspection–see "Certified Electrical form" on Town website
5. Septic Inspection, if needed
6. Final electrical Inspection
7. Stairs & platform covering door width and door swing with handrails on both sides of platform and stairs are
required for all exterior doors.
8. Final inspection by Building & Codes Department
9. All mobile/manufactured housing must be anchored to the ground upon which they are site per
manufacturer requirements.
10. Installer Warranty seal must be provided at the time of Certificate,of Occupancy
11. If anchoring is not possible due to,weather conditions or any other item, a Temporary Certificate of Occupancy
will be issued; Fee-$10; Deposit$100.00 (refunded when all items are complete)
DECLARATIOM. I swear that to the best of my knowledge and belief the statements contained in this application,
together with the pilans, 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 Building Code, the Zoning Ordinance, and all other laws
pertaining to the proposed work shall be completed with,whether specified or not, and that such work is authorized by
the owner. Installer Warranty will be provided at time of Certificate of Occupancy.
Print Name: lae–f7l— 1 Date: Z/ '3 16
Owner, A en , ntractor
Signature: Date:
Special Conditions of Permit:
By: Code Enforcement Officer
2
Town of Queensbury Building&Codes Mobile Home Application July 2014
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INSTALL NO. 23623 STATE N OFSTAT �
DEPARTMENT OF STATE
? ham ONE COMMERCE PLAZA
99WASHINGTON
Y12231 UE
ALBANY,NY 12231 -4 � r
INSTALLER'S WARRANTY SEAL
t�1\ HIS SEAL REMAINS THE PROPERTY OF THE DEPARTMENT OF STATE ZQS — 4p
'--t NEW MANUFACTURED(HUD CODE) ❑ RELOCATED MANUFACTURED(HUD CODE)
A. Manufacturer's name: L"B. HUD Iabel number: Serial number: ( '_1 n/
C. Retailer's name:,
D. Retailer's address: % r'e-- f—
/ ET, 7,5 �G ? rfr) ?ZG iii/ TC'
E. Retailer's cetftfication#: Z � c z Telephone#: -
F. Installer's name: " /--i--f c- S /'/x )
y.
Cx Installer's address: _f 7C
H. Installer's certification#: /_ //i r' , %7�'�i Telephone#:� ) J r i'/<o J G r
I. Date installed: Municipality issuing building permit: ( c "s, /
(age)
J. Customer name and physical address (911)where home is installed: y'
�;NewYork.
By attaching this SEAL to this manufactured home,the undersigned Installer of this manufactured home warrants as follows:
1. That the installation of this manufactured home meets the standards of the New York State Uniform Fire Prevention and Building
Code.
2. That the Installer is certified as an installer by the New York State Department of State.
The foregoing warranties are in addition to and not in derogation of all other rights and privileges which the consumer may have under any
other law or instrument.The foregoing warranties-are in addition to,and not in limitation of or substitution for,any and all other warran-
ties,express or implied,given or made by the t�atle , Kether contractually or by op ation of law
Printed Name of Person Signing Sea/4' L C/
Signature of Installer or
Limited Installer: f
If you have a problem with your home,you should first contact your installer or retailer.If the problem is not resolved by the Installer or
Retailer you can contact the Department of State at(518)474-4073.
DOS-1680(Rev.03109)
Yellow Copy—DepaRment of State White Copy—Retain for Your Records Goldenrod Copy—Permitting Agency Seal—Affixto Home