FMP-0798-2021 r-
FUEL BURNING APPLIANCE & office Use only
CHIMNEY APPLICATION
Permit#: Flvlf - 011V18•Z0ZI
Permit Fee:$ 2-405
Town of Queensbury
742 Bay Road,Queensbury, NY 12804 Invoice#: to
P:518-761-8256 www.gueensbury.net
**ONE APPLICATION PER APPLIANCE**
Project Location: "- 6 ki Tax Map ID#: �J�� •S
Room of Install: Planned Install Date: 11)n V
FUEL BURNING APPLIANCE INFORMATION:
TYPE OF DEVICE:
Stove _Fireplace Insert _Fireplace
_Fuel Fired Equipment (Garage Only: 18" clearance per IMC 304.3)
Fireplace,factory built**
(**Manufacturer's name: )K-ne Model#: Askw
SOURCE OF HEAT:
XWood _Coal _Pellet _Gas
CHIMNEY INFORMATION: PTOWN
W E
Masonry(require plans to be submitted): OCT � �
block _brick _stone
NSBURy
ODES_Flue:
the steel size, in inches
_Material*:
double-wall —triple-wall_insulated
(*Manufacturer's name: Model M )
Fuel Burning Appliance&Chimney Application Revised December 2020
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL.
• Applicant:
Names- ,�du4
Mailing Address, C/S/Z: 1a2 a
Cell Phone: Land Line: � )
Email: ,s
• Prima( Owners :
Name(s)• -fc- k15 JAIIiUf0-
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line: _( )
Email:
`heck if all work will be performed by property owner only
• (Installer/Builder: Workers' Comp documentation must be submitted with this application
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line: _( )
Email:
Contact Person for any questions regarding this project:
Cell Phone:�_) Land Line:
Email:
ADDITIONAL INFORMATION:
1. Two (2) 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.
S. Workers'Comp insurance information is required with this application.
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
me-above: ,.
PRINT NAME: '61.
SIGNATURE: DATE: /G r� r
Fuel Burning Appliance&Chimney Application Revised December 2020