AST-000653-2017 { TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5904 (518)761-8201
Community Development-Building&Codes (518)761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: AST-000653-2017 Date Issued: Friday, December 15, 2017
This is to certify that work requested to be done as shown by Permit Number AST-000653-2017
has been completed.
Tax Map Number: 289.15-1-34.2
Location: 26 SURREY FIELD DR
Owner: Kari Mullan,Thomas Mullan
Applicant: Thomas Mullan
This structure may be occupied as a: Gas Fireplace
Room of Install:Living Room By Order of Town Board
TOWN OF QUEENSBURY
Issuance of this Certificate of Compliance DOES NOT relieve the
property owner of the responsibility for compliance with Site Plan, aa; 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.
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742 Bay Road,Queensbury,NY 12804-5904 (518)761-8201
af Community Development-Building&Codes (518)761-8256
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BUILDING PERMIT
Permit Number: AST-000653-2017
Tax Map No: 289.15-1-34.2
Permission is hereby granted to: Thomas Mullan
For property located at: 26 SURREY FIELD DR
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
Tvpg of Construction
Owner Name: Kari Mullan Fuel Burning&Chimney $0.00
Owner Address: 26 SURREY FIELD DR Total Value $0.00
Queensbury,NY 12804
Contractor or Builder's Name/Address Electrical Inspection Agency
Plans&Specifications
Gas Fireplace
Room of Install:Living Room
$0.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Friday,October 19,2018
(If a longer period is required,an application for an extension must be made to the code Enforcement Officer
of the Town of Queensbury before the exp' ation date.)
Dated at the Town of ueensb Thur er 19,2017
SIGNED BY: for the Town of Queensbury.
Director of Building&Code Enforcement
FUEL BURNING APPLIANCE & office use only
CHIMNEY APPLICATION Permit#: ArST-
_ Permit Fee:$
�p,00
/()1%11 ut(Lurcn.hur Y
742 Bay Road, Queensbury, NY 12804 Invoice:#:
P: 518-761-8256 www.gueensburV.net
Project Location: at, 'quot q F'!dJS t)r. Tax Map ID #: Zai .15 z-
Room of Install: UI VI CA EPlanned Install Date: _ ASAP �
**ONE APPLICATION PER APPLIANOCT 1� 2011 C E 9 V E
CONTACT INFORMATION: �71
10
TOWN OF QUEENSBURY
•
Applicant: BUILDING. I �� BUILDING 8 CODES
Name(s): I YIC�VYIGSS alt
Mailing Address, C/S/Z: Q(p Sl 111Y�.�1 F-d S U U- LL hl
Cell Phone: ( 518 )95S —(oS9ig Land Line:
Email: -1 mu,l I"i i;d 00,c.or�
• Primary Owner(s):
Name(s): �<i� QTS
VC/
�o
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _( )
Email:
• Installer/Builder:
Business Name: Yin c f� ✓1
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _( )
Email:
Contact Person for Building & Code Compliance:
Cell Phone: _( ) Land Line: J )
Email:
Fuel Burning Appliance &Chimney Application Revised March 2017
F
FUEL BURNING APPLIANCE INFORMATION:
TYPE OF DEVICE:
Stove _ Fireplace Insert _ Fireplace
Fuel Fired Equipment (Garage Only, 18" clearance per IMC 304.3)
,Fireplace, factory built**
(**Manufacturer's name: Jj `e_QrN Model #: Ly 50 )
SOURCE OF HEAT:
Wood _Coal _ Pellet ✓ Gas
CHIMNEY INFORMATION:
Masonry (require plans to be submitted):
block brick stone
_ Flue:
tile _steel _size, in inches
✓ Material*:
✓ double-wall _triple-wall_insulated
(*Manufacturer's name_ �lY'Q — Model M so �y A )
ADDITIONAL INFORMATION:
1. Two 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.
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: wlOyil� �T, I.tl� 1
SIGNATURE: DATE: lD I l
Fuel Burning Appliance & Chimney Application Revised March 2017