2013-480 014111111A TOWN OF QUEENSBURY
742 Ba•Road,Quecnsbury,NY 12804-5902 (518) 761-8201
1111111.
Community Development - Building & Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20130480 Date Issued: Monday, October 28, 2013
This is to certify that work requested to be done as shown by Permit Number P20130480
has been completed.
Tax Map Number: 523400-309-009-0002-001-000-0000
Location: 200 LUZERNE Rd
Owner: HOMESTEAD VILLAGE L P
Applicant: HOMESTEAD VILLAGE L P
This structure may be occupied as a:
Fireplace
By Order of Town Board
TOWN OF QUEENSBURY
Issuance of this Certificate of Compliance DOES NOT relieve the ) /A''"
owner of the responsibility for compliance with Site Plan, / /
property P tY p (----/)C 4
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.
004 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building& Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20130480 Application Number: A20130480
Tax Map No: 523400-309-009-0002-001-000-0000
Permission is hereby granted to: HOMESTEAD VILLAGE L P
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 information hereto filed
and approved and in compliance with the NYS Uniform Building Codes and the Queensbury Zoning
Ordinance. Type of Construction Value
Owner Address: HOMESTEAD VILLAGE L P
4294 ROUTE 5 Fireplace
CALEDONIA,NY 14423 Total Value
Contractor or Builder's Name/Address Electrical Inspection Agency
Plans&Specifications
2013-480 169 Elmhurst Dr.
FIREPLACE-pellet stove
$0.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Wednesday,October 15,2014
(If a 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 ensbuf Tu s a October 15,2013
SIGNED BY for the Town of Queensbury.
Director of Building&Code Enforcement
Office Use Only
Town of Queensbury Building & Codes Received:el+T 14 2(113
Tax Map IE)':" ,•_O C�( �
FUEL BURNING APPLIANCE & CHIMNEY APPLICATION PermitN - ►IFENSs i / ,1
Permit F 11..91-, — .. 52)
Application is hereby made to the Building & Codes Office for the issuance of a Building & Use Permit pursuant to the NYS Fire Prevention &
Building Code. 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 all inspectors to enter premises to perform required inspections.
Important Note To Applicant: Rouqh-In and Final Inspections Are Required:
Date /O�/o/ /3
Owner "6 ? L/P7 1 U)Thi. D l� Installer/Builder
Address t 1 k1 PPS )12 U i •k\J Address
Phone l 5 Li O :j 1-3 C7 O Phone , 1
Location of proposed construction and/or installation: /6 L L el A v rsi I�n aiee ►YJ v r''f w � lc)gat-4
Contact Person for Building&Codes Compliance:- ' 1/09 Lf .;C.0 0
Subdivision Name: //0�e S)eG(.t� V r I/ay
Fuel Burning Appliance Information Wood Coal Pellet Gas Oil
Stove
Fireplace Insert
Fireplace,factory built*
Fireplace,Masonry ,
Furnace,(Garage Only)
*If Factory Built, Please Provide: Manufacturer Name: Model No.
Listed By: Number:
Chimney Information
Masonry** ✓check one Block Brick Stone
Flue /check one Tile +Steel _Size in Inches
Material "check one _Double Wall _Triple Wall _Insulated _Direct Vent _Chimney Liner
**If Non-Masonry, please provide: Manufacturer Name: Model No.
Signatures:
Print Name: n YL Vc
Signature: or). � Date: /04O /U ! 3
ADDITIONAL NOTE: CO STRUCTION/INSTALLATION MUST CONFORM TO NYS FIRE PREVENTION & BUILDING CODE
AND/OR MANUFACTURER REQUIREMENTS. CONSULT AVAILABLE TOWN OF QUEENSBURY HANDOUTS REGARDING
REQUIRED INSPECTIONS.
Town of Queensbury Fire Marshal
elf II
742 Bay Road
w . Queensbury,NY 12804
761-8205/761-8206
fax 745-4437
Factory Built Wood Burning Fireplace/Stove Inspection Report
Notice: New York State requires that all UL Listed,factory built appliances be 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.
Permit# r aSchedule Inspection tb 11-4) Time am anytime Inspector Pf‘Ale
Name 10, 110 Address 1 L LWO3SC1 Rough In Final
Appliance Manufacturer Scu-seU JI S Model# 5 — 904 C-
Masonry Chimney Factory Built Chimney Flue Size Double Wall Triple Wall_Insulated_
Yes No N/A Comments
Floor Protection ,°lac. c- ()(PE., A-4 S c,.th,{yam
Clearances to Combustibles (all sides) n� c�
loft(, pa),
Safety Strip Installation (fireplaces only) L
•
Firestop(s) Vertical Chase sw)-1
Wall Penetration
Chimney Clearances to Combustibles /°!y{' )(
Chimney Termination (164,/
3 feet above roof penetration;2 feet above
any combustible construction within 10 feet
Combustion Air /41,vX' 5 1 ,V1*-
Hearth Extension /+h-y
Mantel(height above f/p opening) 1G •'1
Fireplace Doors/Screen (required) 'u)"°/
Carbon Monoxide Detection
White—Building Dept. Ye11oo—Customer Pink—Fire Marshal