application • Office Use Only
itoMANUFACTURED HOME ( Permit#: R-C'mlo 6 • �n.
PERMIT APPLICATION Permit Fee:$ IC(C. - Q
Town of Queensbury
742 Bay Road,Queensbury,NY 12804 fJ N
Rec Fee:S
P:518-761-8256 www.queensbury.net
Invoice#: V)
116 4oki(ono`► o„c\c S�
Project Location: geWfak.itileiteragyk Tax Map ID #: 3d°1 • 9 " a - 1
Name of Park: k- 2' Proposed Date of Placement: 70 t)
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Name(s): S ckatic —
mailing Address, C/S/Z: les4 ems, 1iceeackcAc SI Qsby, )V`Y IoZW'-/
Cell Nhnne• ! SI$ l soR-_415-10 I lnri I !no- i
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rm_lnt: (�C�Z. C.I \ \'le 9 0S'4) Iivc. cowl
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• Primary Owner(s):
LP
Mailing Address, C/S/Z: dox /tq Av1r�./-1Y 'INN
Cell Phone: - SACS' ) 303-S'?" Land Line: _
Em:1E!: hv1►u..tik V ilk my @ live. co.",
• Contractor(s):
Q..r:rcr,. � zrnc: 110 u o c'.c Vilt&y. LP
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Contact Name(c): 94pt4,4 L„8,'Irt41 ,,`
iviaiiing Address, C./S/Z: tidy /SS9 Awn,jw )(lyly
roil pin,np• , S5 303-soli( 1anri ! . ! sl jr ? 5 0?- 9S90
Contact Person for r....ii li ixcY t_cl:;: ?eV.) L ,,)1.{/ti C—tr
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- },Ney..4.014..a..kv11 ci:/ 1;N/4. C...C.vvN.
MANUFACTURED HOME INFORMATION:
(INFORMATION FOUND ON THE PLATE OR STICKER LOCATED IN THE HOME):
Insignia serial #: 113
Name of Manufacturer: i �G,n
Place approval #:
Model or component designation (New Home Only):
Date of manufacture: 02019
ADDITIONAL INFORMATION:
1. Approximate Value of Home: $ 4/6/000
2. Is the home NEW X or a REPLACEMENT ?
3. Single-wide '( or Double-wide ; Size: /y ft. X t r ft.
4. Foundation support (choose one): Size' Depth
)( Piers: a y �
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): 7 r ;#of bedrooms: 3 ;#of bathrooms: 2-
7. Additional heat source? No Yes X Choose one, if yes: gas fp X woodstove wood fp
8. Are there any other/existing buildings on the property? No X Yes ; Explain:
9. What is the water source? �UBLICD PRIVATE WELL
10. Is the parcel on SEWER or aeR-IVATE SEPTIC stem?
11. Do you need a septic permit application? No % Yes
DECLARATION:
swear that,to the best of my knowledge and belief,the statements contained in this application, together with the
plane and specifications submitted, are a true and complete statement of all proposed work to be done on the described
pfeutis_s;a:ud, t«at all provisions of the NYS Building Code,the Zoning Ordinance and all other laws pertaining to the
r,rnnncori work shall be completed with
I have read and agree to the above:
PRINT NAME: (F10\34A-\-- . �..a,,,,,,A,„
:TTUDATE_ 4?//9