RC-0544-2021 Office Use Only
MANUFACTU.RED_H.Ci.M.1 —per- it#: rZ�� OS�I�-•L —Zc�Z�
PERMIT A C TONE 0 r it Fee:$ Z3�• �C�
Town of Queensbury
742 Bay Road,Queensbury,NY 12804 JUL
2 0 ���.� Fee:$ 0�
P:518-761-8256 www.gueensbury.net J�.i
r ` OF GIUEENS__I�Y 0
Inv ice#: 3 r/ 7
L.flOWN
04-UiLDiNG-& CODEES d Zone? Y (D Reviewed By.
Project Location: 'la �c'�� r, S bvry
Tax Map ID#: O l • l� 2��
Name of Park (if applicable): ROM e. -
PROJECT INFORMATION:
1. Proposed Date of Placement:
2. Approximate Value of Home:$ 30'0 Oa0
3. Is the home NEW II/or a REPLACEMENT ?
4. Single-wide or Double-wide Size: _LY__ft.X (of ft.= qS a1— total square feet
5. Foundation support(choose one): Size Depth
"Piers: ZFX �{Fig
Slab:
6. Is the home being placed on a private lot? No Yes"
(**if yes,you must provide stamped engineered drawings of the permanent foundation plan)
7. Total#of rooms(exclude bathrooms): ;#of bedrooms: ;#of bathrooms: t
8. Additional heat source? No Yes Choose one, if yes: gas fp_ woodstove_ wood fp
9. Are there any other/existing buildings on the property? No ZYes : Explain:
10. What is the water source? PUBLIC V 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#:
Name of Manufacturer: 6AAV� I z
Place approval#:
Model or component designation (New Home Only): C
Date of manufacture:
Manufactured Home Application Revised January 2021
4 •
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant: L
Name(s): J0.5t-,+ft.- L
Mailing Address, C/S/Z: Irl C (rh l�rsk Qs— 1Z 954
Cell'Phone: ( SIT ) 3 Z 1 V- Land Line: �)
Email: iews 11•Ca . . c.,
• Primary Owner(s):
Name(s): 0,
Mailing Address, /S/Z: 'led v `o �- a
Cell Phone: ) 3-2.1 Land Line: �)
Email: SeAN & "L, Gvr•� _ _ ____
ER/Check if all work will be performed by the property owner only
•
• Contractor(s): (List all additional contractors on the back of this form)
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone:�_) Land Line: �)
Email:
"Workers' Comp documentation must be submitted with this application"
Contact Person for Compliance in regards to this project: `1
Cell Phone: Land Line: �)
Email:
Manufactured Home Application Revised January 2021
i
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: J65I.wr, f-II!`S
r
SIGNATURE: DATE:
Manufactured Home Application Revised January 2021
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�Ev®RK Department
STATE OF
OPPORTUNITY of Health
ANDREW M.CUOMO HOWARD A. ZUCKER, M.D.,J.D. LISA J. PINO, M.A.,J.D.
Governor Commissioner Executive Deputy Commissioner
August 13,2021
Charles Baker,P.E.
Environmental Design Partnership,LLP
900 Route 146
Clifton Park,NY 12065
Re: Homestead Village Mobile Home Park
Facility ID#56-6911
Lots#62, 97&98,43,44,and 79 Replacement Onsite Wastewater Treatment Systems
Queensbury(T),Warren County
Dear Mr. Baker,
We have this day,approved the plans and specifications for the above referenced project. Application for
this project was duly made by you on plans titled, "Septic Design prepared for Lot 62 Alpine Avenue
Homestead Village;Lot 97&98 Alpine Avenue;Lot 43 Windsong Drive;Lot 44 Windsong Drive;Lot
7 ON e ue ' and were most recently dated June 30,2021. This project includes modification of
the Onsrte as ewater Treatment System serving Lots#62,97&98,43,44,and 79. The replacement
systems consists of a 1,000-gallon septic tanks and 150-feet of absorption trenches to serve 3-bedroom
homes. Approval of these plans is conditioned on the following:
1. That the proposed works be constructed in complete conformity with the approved plans or
amendments thereto;
2. That all components of the proposed works be installed,operated,and maintained as per the
manufacturer's specifications;
3. That approval be granted by other agencies or municipalities having jurisdiction;
4. That the design professional provides inspects the construction and provides certification to this
office that construction was completed in accordance with the approved plans. Certification shall
also be provided to the Town Office Building and Code Enforcement.
The responsibility for the design of the sanitary system lies solely with the design professional and the
proper operation of the sanitary system lies solely with the owner. The purpose of the Department of
Health review is for compliance with the New York State Sanitary Code and in no way guarantees proper
operation. A set of the approved plans is being retained in our files.
Sincerely,
Kevin J.Ke on
Profession Engineer I
Glens Falls District Office
Empire State Plaza,Corring Tower,Albany,MY 122371 health.ny,gov
}
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Cc: Jeffrey Cohen,Affordable Great Locations,Inc.
Dave Hatin,Town of Queensbury
John Schroeder,Glens Falls District Office
Rebecca Bussert,Glens Falls District Office
Maria O'Connell,Glens Falls District Office
Purchase Authorization
PO Number: 21612
Purchaser: Seller:
AGL Homes,Inc. Titan
4305 Route 5 951 Rte 12 South
Caledonia,NY 14423 PO Box 177
(585)226-2727 Fax (585) 226-8909 Sangerfield,NY 13455
Attention: Jinn Davis (900) 937-3911 Fax: (315) 841-4660
AGL Homes agrees to purchase the following unit, described as Model # 8144
Serial # ,for exactly $ . AGL Homes further
authorizes TITAN to submit this unit for floorplaning through
21St Mortgage Cash Program for the exact amount of $ . The described
unit shall not be submitted For payment to the floorplan source prior to actual shipment,
unless otherwise authorized by Russ Corey.
Customer and Delivery Information:
Delivery Address:
Customer Name: 21St Model H9,104*04 Village
Expected Delivery Date: 79 Alpine Ave
Order Number: Queensbury NY 12804.
AFFORDABLE. GREAT LOCATIONS, INC. MUST BE NOTIFIED IN
WRITING OF ANY PRICE INCREASES ABOVE AND BEYOND THE
PURCHASE AMOUNT AS AUTHORIZED ABOVE, AND SUBSEQUENTLY,
A NEW PURCHASE AUTHORIZATION FORM MUST BE COMPLETED
AND SIGNED, IF ACCE TE - AGL HOMES.
Sales Manager Signature: Date: �9 �
Service Manager Signatu e: Date: I i z,!
Project Coordinator Si ature: Date:
General Manager Signature: Date:
Champion Hama Bulider%Inc. Quote-Revision 2
951 Rte.12 South 1�"t'I� No.: OT033111
Sangerfield,NY 13455
Phone:315,841 A122 H Quote Date: 0612412t
Fax:316.841.4660 Retailer P.O.:
order Type: Retail
Retail Customer: Lot#79
Bill To: 1057NY Sell To: 0950NY Req,Dal.Date;
Affordable Great Locations,Inc. Affordable Great Locations,Inc, zone Manager. Jim Davis
Affordable Great Locations,Inc. Homestead Village MHP Brand: TITAN-EAST POINT
4305 Route 5 260 Luzeme•Rd. Model No.: EP8144
Caledonia,NY 14423 Queenab ijry,NY 12804 Base Home: 1072 3 BR 2 BATH
Shawn Adams Model Year: 2022
Model Size: 68'0"X i3'4"
Construction Type: HUD
Shipping Agent:
Shipping County: WARREN
FOB: Factory
Page:1 of 4
Feature Option Variant Description Quantity Ext.Price
Construction
WINDZONE 10198 WINDZONE1 1 Standard
ROOFINS 621 R-30 ROOF INSULATION 907 Standard
ROOFLOAD 10003 30 LB ROOF W124 00 RAFTER 70 Standard
AOOFPITCH 999 3112 ROOF PITCH 70 Standard
FLOORINS 13979 R-11 FLOOR INSULATION 1 Standard
FLOORJST 13688 2X6 FLOOR JOISTS 16"010 1 Standard
SHEATHING 14003 FOAM-CORE SHEATHING 1 Standard
WALLINS 109 8-19 WALL INSULATION 1 Standard
SWALLHT 10077 8'SIDEWALL 1 Standard
FRAME 13480 4"RECESSED FRAME-- I Standard
HITCH 9 REMOVABLE HITCH-PER FLOOR 1 Standard
OTHER 10001 CONTINUOUS RIDGE VENT 1 Standard
Plumbing/Heating
HEATSYS 10044 White GAS FURNACE(ATMO-GAS) 1 Standard
DUCTSYS 12336 IN LINE HEAT FLOOR REGISTERS 1 Standard
WH 10061 30 GALLON ELEC.WATER HEATER 1 Standard
WHACCESS 10117 DRIP PAN FOR WATER HEATER 1 Standard
OTHER 279 WATER SHUT OFFS&MAIN 1
OTHER $23 PLUMB&WIRE FOR WASHER 1 Standard
OTHER 3442 ROOF JACK EXTENSION 1
Champion Is a registered trademark of champion Nome Builders,Inc,
Quote-Revision 2-No.:Q7033111 Model No.: EP8144 Page:2 of 4
Feature Option Variant Description Quantity Ext Price
Exterior
FRONTDOOR 10188 White 3SX60 FRONT DOOR 1 Standard
KEYSTONE
RHH
REARDOOR 13340 White 36,9-CITE 1
KEYSTONE
RHH
SHINGLES 13138 Dual Black 3-Tab Shingles 14 WIDE " 1 70 Standard
SIDING 14280 SELECT VARIANT DOUBLE 4"VINYL SIDING ?+�i t iy1+J 1,962 Standard
OTHER 13458 White STORM DOOR l 1
LHH
OTHER 14206 NON GRID WINDOWS EA. 1 Standard
OTHER 14289 TRADITIONS FRONT END 1
(1)WHITE Ri:STORATION MILL WORK PILLAR
LINEAL HE W(NDOW(NO SHUTTER):WHITE
SIDING COLOR BETWEEN PILLAR AND CORNER:SAME AS SIDING COLOR
INCLUDES 2OUTDOOR LANTERN LIGHTS
OTHER 638 SELECT VARIANT EXTRA RP SHUTTERS-PER SET 3
Electrical
MAINPANEL 10042 100 AMP SERVICE 1 Standard
OTHER 10023 LIGHTS @ ALL EXTERIOR DOORS 2 Standard
OTHER 10048 EXTERIOR GFI RECEPTACLE 1 Standard
OTHER 13713 HUNTER PADDLE FAN 1
OTHER 325 WIRE&VENT FOR DRYER 1 Standard
OTHER 660 CARBON MONOXIDE DETECTORS 1
Interior
DOORS 13598 WHITE 2-PANEL INTERIOR DOORS 1 Standard
ORJAMBS 102DO Umber Oak DOOR JAMBS STD 1 Standard
FLRCOVER 13596 Brownwood LIVE WIRE CARPET 66
DRMOLDING 10213 Umber Oak FLAT DOOR MOLDING 1 Standard
CLGCOVE 10212 Umber Oak FLAT CEILING MOLDING 1 Standard
LOCKSETS 10063 METAL DOOR KNOBS i Standard
CEILINGFIN 10011 STIPPLE TEXTURED CEILING 1 Standard
OTHER 10009 WIRE VENTED SHELF-ALL CLOSETS 1 Standard
OTHER 13612 MINI-BLINDS PER WINDOW 6
Kitchen
DRYWALL 10025 Northwood Mineral VNL CLD GYPSUM WALL BOARD 26 Standard
FLRCOVER 14419 AF010-Wcodgrain ARMOURFLOOR LINOLEUM 18 Standard
CA13INETDR 10065 Umber Oak MDF CABINET DOORS 9 Standard
CABSTILES 12683 Umber Oiled Oak MDF CABINET STILES 1 Standard
CTRTOP 12286 Madura Paarl LAMINATE COUNTERTOP 12 Standard
EDGE 12287 FORMICA EDGING 1 Standard
SINK 10034 Stainless Steel STAINLESS STEEL SINK-KITCHEN 1 Standard
Champion is a registered Iradamark of Champion Hama Sugdors,h1c.
Quote-Revision 2-No.:OT033111 Made]No., EP8144 Page:3 of 4
Feature Option Variant Description Quantity Ext.Price
Master Bath
DRYWALL 10025 Northwood Mineral VNL OLD GYPSUM WALL BOARD 22 Standard
FLRCOVER 14419 AF010-Woodgrain ARMOURFLOOR LINOLEUM 6 Standard
CASINETOR 10005 Umber Oak MDF CABINET DOORS 1 Standard
GABSTILES 12083 Umber Oiled Oak MDF CABINET STILES 1 Standard
CTRTOP 12288 Madura Pearl LAMINATE COUNTERTOP 3 Standard
EDGE 12287 FORMICA EDGING 1 Standard
SINK 546 CHINA SINK 1
TUB 10118 1 PC FIBERGLASS TUB 1 Standard
Hail Bath
DRYWALL 10025 Northwood Mineral VNL OLD GYPSUM WALL BOARD 25 Standard
FLRCOVER 14419 AF010-Woodgraln ARMOURFLOOR LINOLEUM 8 Standard
CABINETDR 10065 Umber Oak MDF CABINET DOORS 1 Standard
CABSTILES 12683 Umber oiled Oak MDF CABINET STILES 1 Standard
CTRTOP 12285 Madura Pearl LAMINATE COUNTERTOP 3 Standard
EDGE 12287 FORMICA EDGING 1 Standard
SINK 546 CHINA SINK 1
TUB 10118 1 PC FIBERGLASS TUB 1 Standard
Living Room
DRYWALL 10025 Northwood Minaml VNL OLD GYPSUM WALL BOARD 74 Standard
Dining Roam
DRYWALL 10025 Northwood Mineral VNL OLD GYPSUM WALL BOARD 13 Standard
Master Bedroom
DRYWALL 10025 Northwood Mineral VNL OLD GYPSUM WALL BOARD 62 Standard
2nd Bedroom
DRYWALL 10026 Northwood Mineral VNL OLD GYPSUM WALL BOARD 49 Standard
3rd Bedroom
DRYWALL 10025 Northwood Mineral VNL OLD GYPSUM WALL BOARD 54 Standard
Utility Room,
FLRCOVER 14419 AF010-Woodgraln ARMOURFLOOR LINOLEUM 4 Standard
DRYWALL 10025 Northwood Mineral VNL OLD GYPSUM WALL BOARD 24 Standard
WASHEROVHD 2882 WASHER/DRYER SHELF 1
Foyer
FLRCOVER 14427 AF010-Woodgraln F..PITRY LINO ARMOURFLOOR 1
Appliances
RANGE 14733 S.S.GAS RANGE" 1 Standard
REFER 14731 S.S.18CU REFER" t Standard
DISHWSHR 14735 S.S.DISHWASHER" 1
MICROWAVE 10028 While VENTED/UGHTED HOOD 1 Standard
OwMian Is a m aleWad tradmS*Or*Wna pa Hama 9UMkm lac.
Quote-Revision 2-No.:QT0331I I Model No.: EPS144 Page.4 of 4
Feature Option Variant Description Quantity Ext.Price
Inflation Protection Plan
DISCLOSURE 14739 IPP DI&CLOSURE I
This homy la subj4ct to an Inflation Protection Plan(IPP)at the Hine of
Invoicing.The quoted amount Includes an IPP surcharge of 1XI abo ve
our base prke.The final Invoice price will be adjusted In accordance
With IPP.
MISCELLANEOUS CHARGES
STATEDUES STATE DUES 130
Requested By: Shawn Adams BASE PRICE. . . . . . .. . . . . . . . . . . . . . . . .$
Champion Home Builders,Inc.reserves the right to make changes at
anytime in pdoes spe tl Whout notice and/or obligation,
SIGNED & . . . . . . . . . . .. .. . . . . . . . . . . . . . . . .
` •� TOTAL FREIGHT CHARGES . . . . . . . . . . . . . . .5
MadiasdDate:o&24m DalenlnooPdntet88r2t*IC4r18PM Manned8y:JMAVIa
Champlon Is a registered Uademark 01 Champion Hama avildsre,Inc.
Jam', W. _ ,Y ., _ •_�:..,.a ,rr� .�d.
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TOWN OF QUEENSBURY
BUILDING & CODE DEPTm FILE COPY
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Date: A �-� C c [E O V L
JUL20L � {
TOWN QUEENSBURI! TOWN OF OUEENSPIURY
BUILDI DEPARTMENT {3UILDING R: p0)D"-S
Based on our limi d examination,c pHance -- - -
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