application Office Use Only
MANUFACTURED HOME - 202-0
Permit#: V-C.' 0
PERMIT APPLICATION
Permit Fee:$ '2-1\
Town of Qeensbury
742 Bay Road,Queensbury,NY 12804 _
Rec Fee: $ nJIPC-
P:518-761-8256 www.queensbury.net •
Invoice#: 1
Project Location: 'yie/[,'`-I ./`& per!• Tax Map ID #: 3O90 /o —5a
(1,u,e-e#iS`J a.^j , Aby-
Name of Park: Proposed Date of Placement:
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CONTACT INFORMATION: AUG 2 7 2020 LL!
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• Applicant: , TOU4 N €�, �,;�z ._:? .. • F
l ' "^ ,, 7JQc�rG' L BUiR!r,;itl
Name(s): C�c,UEi+r'' LOD
Mailing Address, C/S/Z:
Cell Phone: ( 6 I ) 013-2=t cite Land Line: ( /VAii
Email: he r6SAQ5'-', Aeriry, / - °
• Primary Owner(s): _
Name(s): 6�rn
Mailing Address, C/S/Z: �,
Cell Phone: ( ) Land Line: ( )
Email:
❑ Check if all work will be performed by homeowner only
• Contractor(s): j a.5 6,7
Contact Name(s): ���, 6.-�,-Airf2
Contractor Trade:
Mailing Address, C/S/Z: 1,24 61
,Cell Phone: L -, f ) ��_ �l-7®7 Land Line: _(_)
Email: �,� s— I 40 e e , ..
* List all additional contractors on the ba "k of this form
Contact Person for Building & Code Compliance: - p\\«T
Cell Phone: ( ) Land Line: (
Email:
Manufactured Home Application Revised February 2019
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Contact Name(s):
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Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: (
Email:
• Contractor(s):
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Mailing Address, C/S/Z:
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• Contractor(s):
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Mailing Address, C/S/Z:
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• Contractor(s):
Contact Name(s):
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Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: ( )
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• Contractor(s):
Contact Name(s):
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Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: ( )
Email:
• Contractor(s):
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: ( )
Email:
Manufactured Home Application Revised February 2019
MANUFACTURED HOME INFORMATION:
(INFORMATION FOUND ON THE PLATE OR STICKER LOCATED IN THE HOME):
Insignia serial #: O cQL._L 1 D L NA,
Name of Manufacturer: 17 4-er--71�
Place approval #:
Model or component designation (New Home Only):
Date of manufacture: 7 o P- ??
ADDITIONAL INFORMATION:
1. Approximate Value of Home:$ .30, DODAe---trip a f DA
eut'
2. Is the home NEW or a REPLACEMENT ? JP Z
3. Single-wide or Double-wide 4"; Size: aq- ft.X ft.
4. Foundation support(choose one): ] Size Depth
J ,
Piers: 111
f Phq
S ab:
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): ;#of bedrooms: 3 ;#of bathrooms:7. Additional heat source? No ✓ Yes Choose one, if yes: gas fp_ 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 a PRIVATE SEPTIC system? P('I U4. — e'
11. Do you need a septic permit application? No 10 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: CZ!
SIGNATURE: /3 Q,4" � G 6p C' DATE: O'� -2-D a.cO
Manufactured Home Application Revised February 2019
INSPECTION WORKSHEET (000648-2020)
Case Number: BISV-0043-2020 Case Module: Permit Management
Inspection Date: 01/31/2020 Inspection Status: Passed
Inspector: John O'Brien Inspection Type: Building Inspector Visit
Job Address: 44 Windsong Dr Parcel Number: 309.9-2-1
Queensbury, NY 12804
Contact Type Company Name Name
Checklist Item Passed Comments
Building Inspector Notes True 1/31/20 As per my building inspector visit I inspected a double wide
manufactured home for transport from 44 Windsong Dr.to 4
Richardson Street.
Liberty Homes Inc.
Serial#08L-66406xu
NTA962737/NTA962738
Model Designation: MB244425
Date of Manufacture: 7/28/99
September 01,2020 Page 1 of 1