application Office Use Only
MANUFACTURED HOME Permit#: RG—QS�� • 2�5
PERMIT APPLICATION Permit Fee: $ IO . etQ
Town of Queensbury
742 Bay Road,Queensbury,NY 12804 Rec Fee: $
P:518-761-8256 www.queensbury.net
Invoice#: 1�
Project Location: PSAoki ce .ck Tax Map ID #: 369, Z —/
Name of Park: ,Aty(Wi : rtak v A Proposed Date of Placement: Tigb
CONTACT INFORMATION:
• Applicant:
Name(s): 9%,:kyr� �.owrti4vtc�
Mailing Address, C/S/Z: l `Adi renakackc Sr- ( S\t Jll)/ 1c WCf
Cell Phone: ( 51$ ) coo4-c/S-9O Land Line: (
Email: pnu-tle nki t MOS ltrc,., car•
• Primary Owner(s): nc
Name(s): H A Vilt&t L 1'
Mailing Address, C/S/Z: (3ox ) -vo 1, MI /c///y
Cell Phone: ( SfrS ) 303 • S'd1l Land Line: ( S'fS ) 0??4- (o/S7)
Email: \r1orM,.0\-e_eAt villd,eree Ii ft . ram
• Contractor(s): 11
Business Name: \-kvAM�t.o trAck. VAtekty La
Contact Name(s): 1�e,40
Mailing Address, C/S/Z: 80X /S-9 l`-timAY /yt//V
Cell Phone: (StS ) 303 • S'd,/ Land Line: ( S'/Tr ) 54 - 4/59'0
Email: V1ovst.t.oLtrAd iher @ fi,/.e , cow"-
Contact Person for Building & Code Compliance: ?o'3
Cell Phone: ( 511 ) elS 9O Land Line: ( 5g3-) 3o3-Y44i/
Email: rwv ter+-I6+6. h.►..4.4 J,c.adv, /a a I iL,t . cu-•
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 #: -TZ
Name of Manufacturer: k; eN
Place approval #:
Model or component designation (New Home Only): _
Date of manufacture: 020I 9
ADDITIONAL INFORMATION:
1. Approximate Value of Home: $ 40r dU 0
2. Is the home NEW X or a REPLACEMENT ?
3. Single-wide X or Double-wide ; Size: I4.4 ft. x tor ft.
4. Foundation support (choose one): Size Depth
X. Piers: 2
Slab:
5. Is the home being placed on a private lot? No X Yes (if yes, you must provide stamped engineered
drawings of the permanent foundation plan)
6. Total#of rooms(exclude bathrooms): 7 ;#of bedrooms: 3 ;#of bathrooms: 2-
7. Additional heat source? No Yes X Choose one, if yes: gas fp k 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 on SEWER or : PRIVATE system?
11. Do you need a septic permit application? No k Yes
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 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: 7,4\64,4" C `-awUn•...•-
SIGNATURE: Na..T. . DATE: t 12o1///
Town of Queensbury Building&Code Enforcement Manufactured Home Application Revised May 2017