AST-000687-2017 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-000687-2017 Date Issued:
This is to certify that work requested to be done as shown by Permit Number AST-000687-2017
has been completed.
Tax Map Number: 296.57-1-4
Location: 36 DORLON DR
Owner: Christine Partch
Applicant: Christine Partch
This structure may be occupied as a: Gas Fireplace Insert
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,
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
Community Development-Building&Codes (518)761-8256
BUILDING PERMIT
Permit Number: AST-000687-2017
Tax Map No: 296.57-1-4
Permission is hereby granted to: Christine Partch
For property located at: 36 DORLON 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
Type of Construction
Owner Name: Christine Partch Fuel Burning&Chimney $0.00
Owner Address: 36 Dorlon DR Total Value $0.00
Queensbury,NY 12804
Contractor or Builder's Name/Address Electrical Inspection Agency
Plans&Specifications
Gas Fireplace Insert
$50.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Wednesday,November 7,2018
(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):Padate.)
Dated at the Town of ueensbues a , ember 7,2017
SIGNED BY: for the Town of Queensbury.
Director of Building&Code Enforcement
FUEL BURNING APPLIANCE & office Use Only
CHIMNEY APPLICATION Permit#:
$�`G
pn 2 Permit Fee:
Ib+u n%(Zion.+�urc D V L�
Invoice:#:
742 Bay Road, Queensbury, NY 12804
�3fr3
P: 518-761-8256 www.gueensburV.net NOV o 1 2017
TOWN OF QUEENSBURY
�OMUNI EVELOPMENT
Project Location: �J(p ( �-,, ✓�y-Clax Map ID /-
Room of Installd-4 r-. , Planned Install Date: Q,C/✓-e ms •^�/�(.�i.�-
**ONE APPLICATION PER APPLIANCE**
CONTACT INFORMATION: 013Ker
oh d 3/ --617
• Applicant: //. ,, �, 1 �lao A.;t- J,,-- C4;,e
Name(s): Gi Gtr needs
Mailing Address, C/S/Z: 4htLA,(L 4
Cell Phone: -,T 3 y.5- - SSS�? Land Line: ) a Pc
Email:
•
Primary Owner (s):
Name(s): ^�
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _( )
Email:
• Installer/Builder:
Business Name:
Contact Name(s):
Mailing Address, C/S/Z: Jul
Cell Phone: 61 Land Line: _( )
Email:
Contact Person for Building & Code Compliance: (azy've-
Cell
Phone: _( ) Land Line: _( )
Email:
Fuel Burning Appliance &Chimney Application Revised March 2017
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: Model #: )
SOURCE OF HEAT:
—Wood —Coal — Pellet Gas ��l-r
LJoc�,f `7�•-��� l e-Lc
CHIMNEY INFORMATION: lS���7
— Masonry (require plans to be submitted):
block 1,Z brick stone
_ Flue:
—the —steel —size, in inches
_Material*:
—double-wall —triple-wall—insulated
(*Manufacturer's name: Model #: )
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: &&b
SIGNATURE: " A0 A�I DATE: ` 6
4�7—
Fuel Burning Appliance &Chimney Application Revised March 2017