application Office Use-Only
MANUFACTURED HOME Permit#:
PERMIT APPLICATION Permit Fee:$
Toim of Qcensbury _
742 Bay Road,Queensbury;NY 12804
. Rec Fee: $
P:518-761-8256 www.gueensbury.net `
Invoice#:
Project Location:.; LUZe Tax Map ID #:
Name of Park: Vd . Proposed Date of Placement: 331,221,Z7
CONTACT INFORMATION: �C 2 g 20
I �
• Applicant: i OtiJN cat=
Name(s):
Mailing Address,,: Py L�o, ,5�9 ,,�p ✓a-n N�'
Cell Phone: Land Line:
Email: f-e1:5/e42 a.� Lra•-ze_ s , cv
• Primary Owner(s):
Name(s): V, �t -
Mailing Address, C/S/Z: ✓ate AM I Y YZ
Cell Phone: sks ) 36 3 - !75-6 Land Line: (,-A
Email:
❑ Check;if all work will be performed by homeowner only
• Contractor(s):
Contact Name(s): c 37
Contractor Trade: f??i►-M�, e vre cl e3
Mailing Address, C/S/Z: PCB Re K Avow% AZY Zy"//V
Cell Phone: (S95' )_3�03 —7So3 Land Line:` (sus)
Email: i^ 1-m-"
**List a I additional contractors on the back of this.form --
Contact Person for Building& Code Compliance: \ It
Cell Phone: ( ) Land Line:
Email:
Mnniifnrtnrarl Hnma Annlirntinn RPviaarl Fahninr gnici
MANUFACTURED HOME INFORMATION:
(INFORMATION FOUND ON THE PLATE OR STICKER LOCATED IN THE HOME):
Insignia serial#.: H V /,;Z ? 3 8G 2—
Name of Manufacturer: '/17� 1 e-g
Place approval#: 56k,-;* (
Model or component designation(New..Home Only):
Date of manufacture:
Manufactured Home Application Revised January 2021
Ivioaei or component designation (New Home only):
-Date of manufacture:
ADDITIONAL INFORMATION:
1. Approximate Value of Home..$
2. Is the home NEW or.a REPLACEMENT-Z
?.
3. Single-wide or. Double-wide Size: ft.X (a
4. Foundation support(choose one): Size Depth
V Piers:
Slab:
5. Is the home being placed on a private lot? No—Z 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: 2
7. Additional heat source? N,o V 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? 12C
11. Do you need a septic permit application? No V 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
have read and agree to the above: _
PRINT NAME: � ���,Y /C.P4 le—
SIGN-ATURC Di C I'/�k Y DATE: IZ6 I
Mnniifarttirarl Hnma Annliratinn o