RC-000537-2016 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-000537-2016 Date Issued: Thursday, December 29, 2016
This is to certify that work requested to be done as shown by Permit Number RC-000537-2016
has been completed.
Tax Map Number: 309.9-2-1
Location: 200 LUZERNE RD
Owner: Homestead Village
Applicant: Robert Lawrence
This structure may be occupied as a:New Mobile Home in Park
Lot: 162 Elmhurst Drive By Order of Town Board
TOWN OF QUQUEENSBUURY
Issuance of this Certificate of Occupancy DOES NOT relieve the ( .\ �/ 4
property owner of the responsibility for compliance with Site Plan, \ W/ JQyJY
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 QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5904 (518)761-8201
QL
Community Development-Building&Codes (518)761-8256
BUILDING PERMIT
Permit Number: RC-000537-2016
Tax Map No: 309.9-2-1
Permission 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 information hereto filed and approved and in compliance with the NYS Uniform
Building Codes and the Queensbury Zoning Ordinance
Tvce of Construction
Owner Name: Homestead Village Mobile Home $0.00
Owner Address: 200 Luzeme RD Total Value $0.00
Queensbury,NY 12804
Contractor or Builder's Name/Address Electrical Inspection Agency
Plans&Specifications
New Mobile Home in Park
Lot: 162 Elmhurst Drive
$117.60 PERMIT FEE PAID-THIS PERMIT EXPIRES: Friday,August 25,2017
(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 exptionQate.)
Dated at the Town of censb /lOturs ust 25,2016
SIGNED BY: '' for the Town of Queensbury.
Director of Building&Code Enforcement
MOBILE HOME APPLICATION Office Use 0 I
Received
DATE: `6II�I1� Tax Map ID
TAX MAP ID 3c�9 . 5 - 2 —
Permit No. C- `J�j�- 20 1 b
¶ Permit Fee 11 +. b0
_7_0
7
PROPERTY LOCATION: f_ 0 L -2-e,r r\ FLR-A • V�` 92b
IYt
NAME OF MOBILE HOME PARK: �\Dk4 e A \,/1"oaf List t IQ L_ 6)1�t r 1u(Si. �V
PROPOSED DATE/OAF \PLACEMENT: T /J�(P �(p
APPLICANT �)�OQC� I1S�..�I'�2Y\�l..Q`, OWNER RGLC 140'\M9,13
ADDRESS aL-I I�o11( \ Y �T ADDRESS I(a� C,`ri111�3Y.5� �1r
a,)Ie n-lOULu MN Q ,�„a )LA ,kN
PHONE cir- " /1-I�7 p PHONE _ '�S�-o [ri' (j,
NAME OF INSTALLER OR MOBILE HOME DEALER )CSL I'`aYKA-1�-
ADDRESS: 7O C�cX 15-,9
n\fVy,, M1uy)q RECEIVED
PHONE 6T5" 60U LIS- \\ \ i� IS1-2, (b
CONTACT PERSON FOR BUILDING&CODES COMPLIANCE: �a6.11 T ` fuJd ✓1 t_ 0`PHONE:
COMPLETE INFORMATION BELOW FOUND ON A"PLATE"OR"STICKER"WHICH IS AFFIXED TO THE MOBILE HOME
Insignia serial number
Name of Manufacturer GV >1
Place Approval Number
Model or Component Designation (New home only)
Date of Manufacture:
MOBILE HOME INFORMATION ZONING INFORMATION
Approximate Value of Home $ Zoning
New Home or Replacement Size of property ft.by ft.
Size of Mobile Home I I ft,by —/0 ft. Existing buildings
Singlewide or Doublewide Accessory buildings
Number of rooms(exclude bath) Storage buildings
Number of Bedrooms 3 Detached Garage _1 _2 _g
Number of Bathrooms Z Attached Garage —1 _2 _3
Gas Fireplace;Woodstove or Wood Fireplace Setbacks Front yard: ft.
Rear yard: ft.
Side yard: it.
Foundation Support Size Dept!) Water Supply Well:
Piers 2 Municipal:
Runners _
Slab Septic Permit Required? Yes _No
1
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 card is placed on property
3. 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)
DECLARATION. I swear that to the best of my knowledge and belief the statements contained in this application,
together with the plans 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.
QPrint Name: , � Q. Date: �-/f ee
Owner, Agent, Contractor
Signature: Date:
Special Conditions of Permit:
By: Code Enforcement Officer
2
Town of Queensbury Building&Codes Mobile Home Application July 2014
INSTALL NO. 24572 STATE OFNEWYORK �3Z_
DEPARTMENT OF STATE
ONE COMMERCE PLAZA
99 WASHINGTON AVENUE
ALBANY,NY12231
INSTALLER'S WARRANTY SEAL
THIS SEAL REMAINS THE PROPERTY OF THE DEPARTMENT OF STATE
[�NEW MANUFACTURED(HUD CODE) ❑ RELOCATED MANUFACTURED(HUD CODE)
A. Manufacturer's name: /fJ '✓�: — /'/`/� !��/� /
B. HUD label number. /%A/ 7 f' ' Serial number: L' ✓�i/_'�`1:i/t/
C. Retaileesname: /77_/_
D. Retailer's address:
E. Retailer's certificationn##: //TE l/G< G^ / Telephonek: zzc
R Installer's name:
G Installer's address:
H. Installer's certification#: i 22/L J;,! Telephone#:K
I. Date installed: /'L�, Municipality issuing building permit: y
/ (City,Town, Villi e) y
J. Customer name and physical address (911)where home is installed:
Lc,. .r,3,_,.< ./ .New York.
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 b the,Ins er,whether contractuall o by ope on of law.
Printed Name of Person Signing S �7 `--
Signature of histalleror /' �
Limitedhistaller. I d + && 4 A ! L• �'
If you have a problem with your home,you should first co tact 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—Department of State White Copy—Retain for Your Records Goldenrod Copy—Permitting Agency Seal—Affix to Home