2012-349 TOWN OF QUEENSBURY
;row742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development - Building & Codes (518) 761-8256
CERTIFICATE OF OCCUPANCY
Permit Number: P20120349 Date Issued: Thursday, August 23, 2012
This is to certify that work requested to be done as shown by Permit Number P20120349
has been completed.
Location: 158 LUZERNE Rd
Tax Map Number: 523400-309-005-0001-001-001-0000
Owner: D&G MANAGEMENT LLC
Applicant: RICHARD & ANNE EDWARDS
This structure may be occupied as a:
Mobile Home In Park By Order of Town Board
V 3 S `t3a I_ us 2 J, TOWN OF QUEENSBURY
Issuance of this Certificate of Occupancy DOES NOT relieve the property
4/X--
owner of the responsibility for compliance with Site Plan, Variance, or
other issues and conditions as a result of approvals by the Planning Board Director of Building& Code Enforcement
or Zoning Board of Appeals.
TOWN OF QUEENSBURY
` 742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building&Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20120349 Application Number: A20120349
Tax Map No: 523400-309-005-0001-001-001-0000
Permission is hereby granted to: RICHARD &ANNE EDWARDS
For property located at: 158 LUZERNE Rd
in the Town of Queensbury,to construct or place
at the above location in accordance with application together with plot plans and other information hereto filed
and approved and in compliance with the NYS Uniform Building Codes and the Queensbury Zoning
Ordinance. Type of Construction Value
Owner Address: D&G MANAGEMENT LLC
PO BOX 2488 Mobile Home In Park $65,000.00
GLENS FALLS,NY 12801-0000 Total Value $65,000.00
Contractor or Builder's Name/Address Electrical Inspection Agency
VALUED HOMES
793-1266
1572 STATE ROUTE 9
FORT EDWARD NY 12828-0000
Plans&Specifications
2012-349
43 Sugar Bush 28 x 52 Mobile Home
$174.72 PERMIT FEE PAID-THIS PERMIT EXPIRES: Friday,July 26,2013
(If a longer period is required,an application for an extension must be made to the code Enforcement Officer
of the Town of Queensbury before the expiration date.)
Dated at the Town u sbury; Thu s+as July 26, 2012
SIGNED BY C " for the Town of Queensbury.
Director of Building&Co•e Enfor ement
/ - ,
OFFICE USE ONLY
'
• J • ,
• • 061.5-1-1. $ •
TAX MAP NQ. 'PERMIT NO. � �3 ` 9DATE ISSUED:
, I
PERMIT Fh t-)4.1 APPROVALS: ZONING TOWN CLERK JOI. 2, 3 2012
MOBILE HOME - APPLICATION FOR PERMIT:
A building permit must be obtained before placement of mobile home on parcel. No inspections will be made until a
valid building permit has been issued.
Applicant InformationAAProperty Owner Information
Name: k\A-041/�Yl� k L'w 1145 Name: i ► ..A . 1 i 1I lag 1 4
UYAaAd ess: 3 IJ0�� Address: _ .� 1 A� . d
s
re, rV Icy \ u40`1 / i2f 0j
Phone No. 01. .) a,W r t7 Phone No. ,S--fa— 7F,), 0)3Y
Parcel Information ,If
Proposed4 V Date of Placement: a 7 26 Property Location: 1/3 li-m h/Ji)
�Y
^ Road, Street,Avenue
Name of Mobile Home Park: .1liii r\ LiS (if applicable) Tax Map Number:
Mobile Home Informatin l� �. Zoning Information
11
Approximate Value of Home: $19,5;de 11� Zoning Classification:
New Home:BYes ❑No /t Size of Property: ft. by ft.✓k5
Replacement Home: ❑Yes 1J No C I COQ Existing buildings:
Size of Mobile Home: 2 0 ft. by 01 ft. `' p Setbacks: front yard ft. rear yard ft.
side yards ft. and ft.
Singlewide: Doublewide:/_
Number of Rooms: (exclude baths) I(0 Accessory Building(s):
Number of Bedrooms: 3
Number of Bathrooms: 7 Detached garage:❑1-car ❑2-car ❑ car
D Gas Fireplace ❑Woodstove ❑Wood Fireplace Attached garage: ❑1-car 1-12-car ❑ car
Foundation Support: grtolid
h Storage building: ❑Yes ❑No
Type Size & Depth Other:
Piers Water Supply: ❑Well ['Municipal
Runners
Slab Is Septic Permit Required? El Yes 0 N
Continued on page 2
Qv Town of Queensbury • Community Development Office • 742 Bay Road, Queensmiry, iv r 1Lov4
'kbN S
Name of Installer or Mob Home Deal r: �1,.` `
Address: ' '72 g r: I W Pfi�' Phone: 5t5 f 3 — 140
0 z�2d
Complete information below found on a"Plate"or"Sticker"which is affixed to the mobile home:
✓ Insignia serial number: /21 a OoO H - rJ 0 13 11 46
✓ Name of manufacturer: (\Q11\-\,p1 p,n
✓ Plan Approval Number: ``
✓ Model or Component Designation: Iv N1 0 A' 4 9 g Re.c1 rC\a nJ Neu`' M Do c
(New home only)
✓ Date of Manufacture: A 013
AFFIDAVIT
Town of Queensbury State of New York :_
County of Warren 7.
7.
•
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 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. 7.
7.
•
Si7. gnature: 2,2-, ,-C �,/� �`�
7.
Owner, Owners Arc ent,Architect, Contractor
SPECIAL CONDITIONS OF PERMIT
Ayri___
By: 4 /
C r Enforcement Officer
Ctt Town of Queensbury • Community Development Office • 742 Bay Road, Queensbury, NY 12804
Queensbury Building & Code Enforcement — Manufactured / Modular Final Inspection
Office No. (518) 761-8256 Arrive: am/pm Depart: 1)Ascamip.
Date Inspection request received: Inspector's Initials:
NAME: PERMIT#.-441701411 -
LOCATION:
v I -
LOCATION: 4DATE: 01'2.
Manufactured Home
Modular Home
Footings_ Foundation_ Backfill— Framing
Comments:
Yes 1 No WA
Foundation support,pier spacing,
Per manufacturer17/
Anchoring per manufacturer 2'from ends
Water line shut off
Sewer line support @ 4 feet
Heating Crossover[doublewide}off grd.
1:(/Dryer vented outside
Skirting ventilated 1 sct.ft.ner 1.500 su.ft.
Hot water relief valve piping outside
Deck,porches,steps,railing
Fumace/hot water operating
Garage Fire proofing YYY .
Fire Door I Door losers (�
Plumbing Fixture/3"Vent through roof[Modular]
Foundation insulation[if applicable]
Smoke/Carbon Monoxide Detectors/Interconnected W/
Final Electrical
Variance required Y
Data Plate okay
Manufactured HUD seal okay /
Warranty Seal after January 1,2006 V, /
Installers Warranty Seal Y
18"x 24"access or 22"x 30"attic access
Vapor retarder under home 6 mil poly or other
911 Street number
Okay to issue C/C or C/O[Temp./Perm.] n
Model# 1\5 I''4beW Serial# "7.7 000)(16.4 -P?'t
Manufacturer 1.144 0`--Gtp
'"k �(j\ fiff)/0.1,
Date of Manufacturer 1T1 114,,
L:lPam Whiting120101Building Codes Forms\Manufactured Modular Final Inspection_03 04 10.doc
INSTALL NO. 17855 STATE OF NEW YORK
DEPARTMENT OF STATE
iz ONE COMMERCE PLAZA
,'1 ' 99 WASHINGTON AVENUE
ALBANY,NY 12231
INSTALLER'S WARRANTY SEAL
THIS SEAL REMAINS THE PROPERTY OF THE DEPARTMENT OF STATE
Er NEW-MANUFACTURED(HUD CODE) ElRELOCATED MANUFACTURED(HUD CODE)
A. Manufacturer's name: R à\f'1 A
B. HUD label number: Serial number: 14 ;.. 139-57;.0
C. Retailer's name: �i,l 1 i L;tv
D. Retailer's address: t 5 7. it)n�c ,Ni
E. Retailer's certification#: t :l T i) �z PTelephone#: i '
� a
Installer's name: U r4 ( ( rj,( 1(!T r
4 Installer's address: / 5 I j I j Ft /w- ' N / =S
H. Installer's certification#: T rV Til(1~L i
�- �, Telephone#:
1. Date installed: f i ti• G U I` Municipality issuing building permit: ,hS i7r.
.((City, Town, Village)
I. Customer name and physical address (911)where home is installed: /? ''h z P"1 i f'4 I"; i
(j /$ j r'ji rt it rm� ri { i (I J ' S�� New York. , tit!
'
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 warran-
ties,express or implied,given or made by.the Installer,,whether contractually or by operation of law.
Printed Name of Person Signing Seal: brif.'( N"t` /WI
Signature of Installer or
Limited Installer: / ' i ' (4/1 ` es,
If you have a problem with your home,you should first contact your installer 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-1880(Rev.03/09)
Yellow Copy—Department of State White Copy—Retain for Your Records Goldenrod Copy—Permitting Agency Seal—Affix to Home