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Fire Marshal's Office Town of Quecnsbu y,742 Bay Road,Queensbury NY
(518)761-8205 '
, Application four Fuel Burning Appliances & Chimneys
applicable to solid fuel &vented gas appliances n
Date , 20 Permit No.0,3 - 'IS? '9
. Application is hereby mace to the Building& Codes Office for the issuance of a Building and Use
Permit pursuant to the New York pate Fire Prevention and Building Code. 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 all inspectors to enter premises to perform required inspections.
NOTE to applicant: Rough-in and,Final Inspections are required.
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Applicant Information Fuel Burning Appliance Information .
(circle appropriate words) -
Name: 6+ • -- N T u 4i iota ) t 4, Stove:' wood coal pellet _gas
Fire lace i sert
Address: `�c€ MT - „�i��`��..,, 1�.a"i
Fire lace factory-built: wood as
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t ' °'s 'I Fireplace, masonry: wood gas
mace wood as oil
Phone: 14VA , 5 ',
If non-masonary applicance, please provide
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Owner: N/A, . Manufacturer Name: `` �`. ` -
Address: •
Model Number:
11
.- ._ Chimney-Information'
. -Phone:- - (circle appropriate words) •
• Masonry block brick stone
c? Flue tiles eel. size: e inches
Exact Address: Gila" hi V l
. of constr`nction'or installation ; Factory-Built
Manufacturer name: " 12
Model Number:
Note: Listed By: Number:
Construction/Installation must .
conform to NYS Fire Prevention &Buuilding • Indicate(circle) chimney material:
Code. Consult available Town of Queensbury
Double wall / Triple wall / Insulated / - Direct •
Handouts regarding required inspect orzs. P venting
Chimney Liner .
ICstisubfer'rer Depnz►tment-Z`oi coif zze eiz bury, Xew z'l3:
Fire Marshal Code# $Collected $RL,undc Received from (refiuzdecl to): �._ ' ''1, t7 t1 ��...ly;St�' '.
•
r address: - -
A 173 3389 (190) Public Safety ' ' 1
A 233 2655 (230)Minor Sales ,= : 11.
DATE A_(e.'; ( -L.-I.'.,,-,....„7... ,
fI►�.�
„ &— T„„ncepo. D y,...
White / Green(Fire M r ) / Yellow.(Bldg.Dept.) / Pink&Goldenrod(Cashier's Dept.) -
(Applicant)
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