RC-0517-2018 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-0517-2018 Date Issued: Thursday, November 1, 2018
This is to certify that work requested to be done as shown by Permit Number RC-0517-2018
has been completed.
Tax Map Number: 309.9-2-1
Location: 1 Windsong DR
Owner: Homestead Village
Applicant: Homestead Village
This structure may be occupied as a: New Manufactured Home 952 s.£
By Order of Town Board
TOWN OF QUEENSBURY
Issuance of this Certificate of Occupancy DOES NOT relieve the
property owner of the responsibility for compliance with Site Plan, �d
Variance, or other issues and conditions as a result of approvals bythe ,
pp Director of Building&Code nforcement
Planning Board or Zoning Board of Appeals.
- v TOWN OF QUEENSBURY
j' '4 leak ;,
_ :,tr 742 Bay Road,Queensbury,NY 12804-5904 (518)761-8201
Community Development- Building& Codes (518) 761-8256
BUILDING PERMIT
Permit Number: RC-0517-2018
Tax Map No: 309.9-2-1
Permission is hereby granted to: Homestead Village
For property located at: 1 Windsong 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: Homestead Village Mobile Home $40,000.00
Owner Address: 200 Luzeme RD Total Value $40,000.00
Queensbury,NY 12804
Contractor or Builder's Name/Address Electrical Inspection Agency
Homestead Village
200 Luzern RD
Queensbury,NY 12804
Plans&Specifications
New Manufactured Home 952 s.f.
$ 190.40 PERMIT FEE PAID -THIS PERMIT EXPIRES: Wednesday,August 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 Quee bury; 4 Tu-..,y t .a t 14,2018
SIGNED BY: '`' \ for the Town of Queensbury.
Director of Building&Code Enforcement
Office Use Only
. �" MANUFACTURED HOME Permit#: 12, C ` 0 ri —2 l'
PERMIT APP (� �(f Permit Fee:$ C oro, `IO
Tativn Qu DE eensGurp E C � U V Lis ,�
742 Bay Road,Queensbury,NY 12804 Rec Fee:$ /v
P:518-761-8256 www. ueensbu in
• AUG 10 2018 Invoice#: 0 Z S cir
TOWN OF QUEENSBURY l
BUILDING&CODES
Project Location: Wir e Tax Map ID#: 3 07, c-2 l
Name of Park: -10144, ^ W ro,)o, Proposed Date of Placement: \- 2 )V
e t
CONTACT INFORMATION:
• Applicant:
Name(s): r)\*
Mailing Address, C/S/Z: \*tA). s\o iJV
Cell Phone: ( 1r ) So gcgro Land Line: s( )
Email: m02.i e. ke..10 q toc€ Mie
• Primary Owner(s):
Name(s): qil ,k (r-;\ \PAa. „A NVoL. G-ko e,6
Mailing Address, C/S/Z: Poo a3o ® '9 D- -a 4W aqq i//
Cell Phone: ( cAF. ) Land Line: ( ma's ) -
Email: c_c G ‘itleirma4d c
• Contractor(s):
Business Name: )40 VIttovt. L?
Contact Name(s): Woo
Mailing Address, C/S/Z: siJ4
Cell Phone: (cc ) 303-Sit o Land Line: (
Email: /U4 A vl1t
Contact Person for Building & Code Compliance: ?c; c
Cell Phone: ( S- ) '10'1 o S 2 / Land Line: ( )
Email: 'V oaAl�a Loan+;
Town of Queensbury Building&Code Enforcement Manufactured Home Application Revised May 2017
MANUFACTURED HOME INFORMATION:
(INFORMATION FOUND ON THE PLATE OR STICKER LOCATED IN THE HOME):
Insignia serial#: •
Name of Manufacturer: ', . \-k.eyw oc +
Place approval It
Model or component designation (New Home Only):
Date of manufacture:
ADDITIONAL INFORMATION:
1. Approximate Value of Home:$ gO,
2. Is the home NEW or a REPLACEMENT ? i pf�
3. Single-wide �C or Double-wide ; Size: Ili ft.X lQ b ft.
4. Foundation support(choose one): Size Depth
Piers:
Slab:
5. Is the home being placed on a private lot? No Yes . (if yes,you must provide stamped engineered
drawings of the permanent foundation plan)
6. Total#of rooms(exclude bathrooms): C ;#of bedrooms: 3 ;#of bathrooms: 2.-
7. Additional heat source? No Yes . Choose one, if yes: gas fp X, woodstove_ wood fp
8. Are there any other/existing buildings on the property? No & Yes ; Explain:
9. What is the water source? !(PUBLIC PRIVATE WELL
10. Is the parcel o '/Sr EWER oar a PRIVATE SEPTIC system?
11. Do you need a septic permit application? No X Yes
DECLARATION:
1 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 NYS Building Code,the Zoning Ordinance and all other laws pertaining to the
proposed work shall be completed with
I have read and agree to the above:
PRINT NAME: - _ 1.
SIGNATURE: c7-2Y-L•S‹..YL) DATE:
/i
Town of Queensbury Building&Code Enforcement Manufactured Home Application Revised May 2017
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TOWN OF QuEENstTRy 1'
. BUILDING&GGDES
INSTALL NO. -# STATE-OF NEW PORK -
2
DEPARTMENT OF- STATE
t
r►� ONE COMMERCE PLAZA
99 WASHINGTONAVENUE
ALBANY,NY 12231
INSTALLER'S WARRANTY SEAL
-Tigs SEAL REMAINS THE PROPERTY OF THE DEPARTMENT OF STATE
NEW BAN M--!CURED(IUD CODE) ❑ RELOCATED MANUFACTURED(HUD CODE)
A. Manufacturer's naive: Corn
Q _
B. HUD label number: et `"_ Serial number:
C. Retailer's name: RCcorckahk t. (Arta L '1 3rk D. Retailer's address: L33Ô . CcUrc1ôn &- 11\JC(\ Qd < C1edor4 .. i i 4 Z 3
E. Retailer's certification#: I E t -‘Ct -..OC)k Telephone_#:
F. Installer's name: C
Q Installer's adder ss: 4-R O Cu.k i (>1\1 A.kiorN 1 CrtMcn l a J'4 it-IL-It-3-
H.
Installer's certification#: '�Q - - -. Telephone#: — 226 �` =`
I.` .Date installed: 10121 ZOAS Municipal ty_.issuing building permit: -C �
• City,.Town,Village)
f f -0.401ftiatiffe and physical address(911)where home is installedv VA PiOSO rm3
:
k.) �' t. � ,Newyork:
By attaching this SEAL -this manufactured home,the undersigned Installer of this manufactured home warrants as follows;
I. That the installation is manufactured home meets the standards of the New York State Uniform Fire Prevention and Building
Code.
2. That thelnstalier is certified asan installer by the New York State Department of State.
The foregoing warranties are in addition 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 by th er,whether co ctu y.or by operation of law.
Printed Name of Person Signing •
Signature of Installer or ..�
Limited Installer:
If you have a problem with your home,you should first contact pur 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.03/09}
h
-Yel Ni of State White C•• —Retain for Your Recces` rod Copy-Permitting Agency_. Seal-Affixto fo