RC-0449-2021 F iA
Office Use Only
MANUFACTURED HOME Permit#: ` al� 2021
PERMIT APPLICATION permit Fee:$ �•�-�
Town of Queensbury
742 Bay Road,Queensbury;NY 12804 -
P:518-761-8256 www.queensburV.net Inv Fee:$ (� h
nvoice#:
Flood Zone? Y N Reviewed By:
Project Location:
Tax Map ID#: ✓�� �_ l —�
Name of Park(if applicable): al�x�25
PROJECT-INFORMATION:
1. Proposed Date of Placement: S� h.er ska
2. Approximate Value of Home:$ ISO
3.. Is the home NEW � or a REPLACEMENT ?
4. Single-wide or Double-wide ; Size: ft.X ft.
S. Foundation support(choose one): Size Depth
Piers:
Slab: A- +Z' 10 Odclirl�7 '�o
6. Is the home being placed on a private lot? No—)L Yes** tf(a's x 22'
(**if yes,you must provide stamped engineered drawings of the permanent foundation plan)
7. Total#of rooms(exclude bathrooms): 7 #of bedrooms:. #of bathrooms:_
8. Additional heat source? No A— Yes Choose one, if yes: gas fp_ woodstove_ wood fp
9. Are there any other/existing buildings on the property? No Yes AL; Explain:
10. What is the water source? PUBLIC_)( PRIVATE WELL
11. What type of wastewater system'is on the parcel? SEWER PRIVATE SEPTIC
12. Do you need a septic permit application? No Yes
MANUFACTURED HOME INFORMATION:
(INFORMATION FOUND ON THE PLATE OR STICKER LOCATED IN THE HOME):
Insignia serial #: 772f)
Name of Manufacturer: RQd.rr,Q,r,
Place approval#:
Model or component designation (New Home Only):
Date of manufacture:2&/Y� P�— 1
Manufactured Home Application Revised January 2021
REQUIREMENTS FOR SUBMITTAL:
1. Completed Manufactured Home permit application
THREE (3) COPIES OF THE FOLLOWING:
2. Structural drawings, which include:
a. Floor plan
b. Foundation plan (see 2015 IRC Appendix E Section AE502:foundation systems)
c. If the home is being placed on a private parcel (not in a manufactured home park or designated
zone),you MUST provide stamped engineered drawings of the permanent foundation plan.
3. Plot plan, using a survey map if possible,which includes:
a. Drawn to scale (i.e. 1 inch =30 feet)
b. Indicate proposed location, with setbacks
c. Include all structures on the property
d. Include location of water supply(well or water lines)
e. Include location &configuration of septic system or sewer line
ADDITIONAL SUBMITTAL INFORMATION:
1. Installer Warranty seal must be provided prior to issuing Certificate of Occupancy.
2. Any changes to the approved plans prior to or during construction will require the submittal of
amended plans, additional reviews and re-approval.
3. If,for any reason, the building permit application is withdrawn, 30% of the fee is retained by the
Town of Queensbury. After 1 year from the initial application date, 100% of the fee is retained.
4. Workers' Comp insurance information for all contractors involved—REQUIRED, EVEN FOR SOLE
PROPRIETORS
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 complied with,whether specified or not,and that such work is authorized by the owner.
I have read and agree to the above:
PRINT NAME: Me i 5sn A 6o raid n
SIGNATURE: A" a&h& . DATE:
Manufactured Home Application Revised January 2021
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" TOWNDF QUEENSBURY Fex:315-28G212052s , w • ` .
sC.AV, '""= '0. BUILDING & CODES DEPT. Email:ken.robeftpe@gmaii.00m
JUN 10 2021
Considering the ago and Past perfomiance.ofthe slab,I found the existingoonemte slab tobe�eviewe� • 'GaN ETE S4f6 PZ�J •L-DG�.q•/LS
very good condition will no eviderta off}ost heave,m severe erackingeaused byfrostand n
adverse effects of frost oa the slab that world have a negative impact an a fuuae home placed— TOWN
p rA' O C/� aaAla o 6 APPIMED on
a it The slab is sound and stable and its continued my P n,i +ate• N r QUEENSBURY
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INSTALL NO. 31896 STATE OF NEW YORK � 2�
DEPARTMENT OF STATE
ONE COMMERCE PLAZA
i 99 WASHINGTON AVENUE
Ltt%.,^4V i ALBANY,NY 12231
• INSTALLER'S WARRANTY SEAL
THIS SEAL REMAINS THE PROPERTY OF THE DEPARTMENT OF STATE
❑k NEW MANUFACTURED(HUD CODE) ❑ RELOCATED MANUFACTURED(HUD CODE)
•
A. Manufacturer's name: CI kr3 n --PA i l t A o r c rn ct P, H O f'f1 f' S
B. HUD label number: PPS 1 a,r:iI a or)-2., 4 6'F�S 161(1 A 00 4 Serial number: 12 - 000- tt•�'R•c/( 5-3r) AL
C. Retailer's name: =rar_ora t-/Si E r Ifni `L nr r 1 v- f"r�PCirP-CA , IP_c
D. Retailer's address: 1-c,!- Li 1—n e4 C d!a t''r r41 N r/ I a, R
E. Retailer's certification#: I A, f;'7"' (-) Telephone#: (51'R )L-I-D
F. Installer's name: P r 1 \I I oi,t 5 i r ci Sr, Fria( Li J i P'+f; , I--tc.->i'Yl P
r/
G. Installer's address: ^r ct -r, 1F� .)/4 v 1 1=1 n- P r'CI n ,*i 1 N V 1 a I O
H. Installer's certification#: _jj 1 AT c'7 ! '77 Telephone#: (3I.8) 5-5 1(17 I. Date installation completed: 1/ 1 Municipality issuing building permit: •-(n \ t�u r GIP 'r h U b'Li
(City Town,Yllage) a
J. Customer name and physical address(911)where home is installed: t`A ,1 r Ste,r; ,rri r,r\ i- 1\1
.ern 5Pi ree ( nr�n 1Dri f e i.a PPr\S art , N�l 1 kQ ? ,NewYorlc.
. _ J/ r
By attaching this SEAL to this manufactured home,the undersigned Installer of this manufactured home warrants as follows:
1. That the installation of this manufactured home meets the standards'of the New York State Uniform Fire Prevention and Building
Code.
2. That the Installer is certified as an installer by the New York State Department of State.
The foregoing warranties are in addition to and not in derogation of all other rights and privileges which the consumer may have under any
other law or instrument.The foregoing warranties are in addition to,and not in limitation of or substitution for,any and all other
warranties,express or implied,given or made by the Installer,whether contractually or by operation of law.
Printed Name of Person Signing Seal: p —ir a( R U ch
Signature of Installer or
Limited Installer: G^ 1✓
If you have a problem with your home,you should first contact youinstaller or retailer.If the problem is not resolved by the Installer or
Retailer you can contact the Department of State at(518)474-4073.
DOS-1680(Rev.06/18)
Yellow Copy—Department of State White Copy—Retain for Your Records Goldenrod Copy—Permitting Agency Seal—Affix to Home
ECEUV
JUL 9 2021
TOWN OF.QUEENSBURY
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