application Office Use Only
MANUFACTURED HOME Permit#: Z)bQ� • 202-0
PERMIT APPLICATION Permit Fee:$
Town of Q_ueens&ry
742 Bay Road,Queensbury,NY 12804 Rec Fee:$
P:518-761-8256 www.gueensbury.net
Invoice#:
Project Location:; 7 Tax Map lD#:
Name ofPark: Vi, 21
�le Proposed Date of Placement: J?/��/Z�
600l
CONTACT INFORMATION:
C 29 2020 ;''
Applicant:
710`,�(iN 01:-'
Name(s):
Mailing Address, 61SIZ: i>':::) sii.� J5---9
Cell Phone: ( 59S ) 30.-7, - 76'<:5 9 Land Line: 67ff 67 ;2,2�-�IS2) 3 11
Email:. I Ce.) �
V
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Primary Owner(s):
Name(s): or, 5jrad , (- P
Mailing Address, C/S/Z: e6 >e- rsf�- ' 1JV&r%,t A)i&"
Cell Phone: (-5-2PS- ) 36 3 - 75-6 8 Land Line:
Email:.
❑ Check if all work will be performed by homeowner only
0 Contractor(s):
Contact Name(s):
Contractor Trade: zrw--Og
Mailing'Address, C/S/Z: e!1 Rox., A4-,
Cell Phone: (S�5 ) 3-05- 7-42T Land Line: (5;?5- ) 2aG - 4/SP X
Email: ',re i'Q le- ea aj! Z eg �
*list all additional contractors on the back of this form
Contact Person for Building & Code Compliance:
Cell Phone: Land Line:
Email:
Manufactured Home Application Revised February 2019
j ACTURED HOME INFORMATION:
FORMATION FOUND ON THE PLATE OR STICKER LOCATED IN THE HOMEj:
/ ignia serial#: H V_
, me of Manufacturer: f 1 d�
Place approval#: l 9
Model or component designation(New Home Only):
Date of manufacture: 1 D
Revised January 2021
Manufactured Home Application
Date of manufacture:
ADDITIONAL INFORMATION:
1. Approximate Value of Home: $ 28t Cioz_-)
2. Is the home NEW or a REPLACEMENT ? Q
3. Single-wide or Double-wide ; Size: —&—ft.X O ft. �5 Z AtA t f
4. Foundation support(choose one): Size Depths
/Piers: y /biJ ly`
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): S ;#of bedrooms: 3 ;#of bathrooms: 2
7. Additional heat source? No �1/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? 12Ct V6,4�
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
I have read and agree to the above:
PRINT NAME:
SIGNATURE: el +� -L K� �T DATE: 02(
Manufactured Home Application Revised February 2019