FMP-0349-2018
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: FMP-0349-2018Date Issued: Friday, January 4, 2019
This is to certify that work requested to be done as shown by Permit Number
FMP-0349-2018
has been completed.
296.50-1-11
Tax Map Number:
31 WALKER LN
Location:
Mitchell Potvin
Owner:
Mitchell Potvin
Applicant:
This structure may be occupied as a: Gas fireplace insert (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,
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: FMP-0349-2018
Tax Map No: 296.50-1-11
Permission is hereby granted to: Mitchell Potvin
For property located at: 31 WALKER LN
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: Mitchell Potvin Fuel Burning&Chimney $0.00
Owner Address: 31 WalkerLN Total Value $0.00
Queensbury,NY 12804
Contractor or Builder's Name/Address Electrical Inspection Agency
First Flame
475 CORINTH RD
Queensbury,NY 12804
Plans&Specifications
Gas fireplace insert(Living Room)
$ 125.00 PERMIT FEE PAID -THIS PERMIT EXPIRES: Friday,June 14, 2019
(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 o ue ury; 4 Thu s a -14,2018
SIGNED BY: 0% for the Town of Queensbury.
Director of Building&Code Enforcement
FUEL BURNING APPLIANCE & office use only
CHIMNEY APPLICATIO tI` ; _ Permit#: F LLM �— G 3Li
01W
I Permit Fee:$ 2 S • U D
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JUN 13 2018 Invoice:#: 4 � ��.�
742 Bay Road, Queensbury, NY 12804
P: 518-761-8256 www.gueensbury.net
Project Location: .31 k"Jg d-'r /—,9 Me-- Tax Map ID
1.
Room of Install: 11 Yl li g A o/x^ Planned Install Date: I-lo n t
**ONE APPLICATION PER APPLIANCE**
CONTACT INFORMATION:
• Applicant:
Name(s): /1')z t,�,1 -r AIM M A P/ V`/tI
Mailing Address, C/S/Z: � � 1,rJ�/ - ,Lgwe....
Cell Phone: �_) Land Line: S1? ) 7 y7—o1-17%
Email:
• Primary Owner(s):
Name(s): 4-6
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _( )
Email:
• Installer/Builder:
Business Name: rlg T
Contact Name(s):
Mailing Address, C/S/Z: (!efi/ox Rol
Cell Phone: _( ) Land Line: _( )
Email:
Contact Person for Building & Code Compliance: � ?� 4 C& 4 ro rtllA/ �i2. DO
Cell Phone: _( ) Land Line: _( 6'18' ) r 4i7-6 k/7/
Email:
Fuel Burning Appliance &Chimney Application Revised March 2017
FUEL BURNING APPLIANCE INFORMATION:
TYPE OF DEVICE: /
Stove y 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
CHIMNEY INFORMATION:
Masonry (require plans to be submitted):
block 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: Mi7c%�#1 -r o7VrN '4 L DpS
SIGNATURE: c DATE: 'dWly
Fuel Burning Appliance &Chimney Application Revised March 2017