application FUEL BURNING APPLIANCE &
CHIMNEY APPLICATION Office Use Only
3 '°
,. Permit#: F14" t' ZO I
, Permit Fee:$ 12
T wn of(Zuecnshnn•
742 Bay Road,Queensbury, NY 12804 Invoice* 1 2Z
P: 518-761-8256 www.queensbury.net
Project Location: `/ iJ !r,eLy 7� Tax Map ID #: ) `I L S) -- I 33 • \
Room of Install: i`.('Z Planned Install Date: t( zl ) l
**ONE APPLICATION PER APPLIANCE**
CONTACT INFORMATION:
• Applicant:
Name(s): D J1 o A-Ey/hook
Mailing Address, C/S/Z: LH gkaart ,1-f pk, ,,,t(A;s ,A y t 2- c y
Cell Phone: ( > ! 6 ) I y 1 — '1 7 v` Land Line: ( 5 /P ) 113— 24. l Z-
Email: 'ey pv.c u r- J 4 1`e 4.44 rclnnai-- •Co wi
• Primary Owner(s):
Name(s): —
Mailing Address, C/S/Z: ��� 0
--'.----" E\ '
Cell Phone:_( ) , / Land Line: _( )
Email: 11/ DEC 12 2018 k
u
• Installer/Builder: TOWN OF OUEENSBURY
Business Name: -) r� dr BU11 DING& C0D B
Contact Name(s): NN il.r
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line: _( i r ) gt: _ ?Lib
Email:
Contact Person for Building & Code Compliance: ')A (t 19 S'i yam 0 L!
Cell Phone: 3 fl p ) 7/ I `70 f Land Line: _( 51 k ) i 3— to 1 y
Email: ';'&21 w.ovo,a At 0 kiiA- P—or✓.[-f, f,i 01
Fuel Burning Appliance&Chimney Application Revised March 2017
FUEL BURNING APPLIANCE INFORMATION:
TYPE OF DEVICE:
Stove _ Fireplace Insert X Fireplace
Fuel Fired Equipment (Garage Only, 18" clearance per IMC 304.3)
Fireplace,factory built**
(**Manufacturer's name: tAt.A-r- .) Model#: , L—`> X eN+
SOURCE OF HEAT:
Wood Coal _Pellet is Gas
CHIMNEY INFORMATION:
Masonry(require plans to be submitted):
block brick stone
Y, Flue:
tile _steel 6=(v size, in inches
✓ Material*:
x double-wall _triple-wall insulated
(*Manufacturer's name: tc}as /0 6 L t_f J 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:
SIGNATURE: C. `f yt DATE: 17,( i le?'
Fuel Burning Appliance &Chimney Application Revised March 2017