FMP-0806-2021 FUEL BURNING APPLIANCE & office Use Only
CHIMNEY APPLICATION Permit#: i�/h y Sod' `��
Permit Fee:$
Town of Queensbury
742 Bay Road,Queensbury, NY 12804 Invoice#: 4t
P:518-761-8256 www.gueensbury.net
**ONE APPLICATION PER APPLIANCE**
Project Location: ! 0�.1 I-��'C' Tax Map ID#: -/��Or 517 3
Room of Install: Planned Install Date:
FUEL BURNING APPLIANCE INFORMATION: D C
TYPE OF DEVICE:
Stove Fireplace Insert _Firepl ce NOV 0 7 2021
TOWN OF OUr::ENSI3URy
Fuel Fired Equipment (Garage Only: 18 clearance per IMC 304.3 BUILDING e OOD,S
Fireplace,factory built**
(**Manufacturer's name: Model #: GS )
SOURCE OF HEAT:
Wood _Coal _Pellet Gas
CHIMNEY INFORMATION:
Masonry(require plans to be submitted):
block brick stone
_Flue:
the _steel size, in inches
_Material*:
_double-wall —triple-wall_insulated
(*Manufacturer's name: Model#: )
Fuel Burning Appliance&Chimney Application Revised December 2020
}
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant: �l
Name(s):
Mailing Address, C/S/Z: L� �U2 Co ou �-
Cell Phone: ) 76 C Land Line: LQ L? OS R-6
Email: L A-510 Cl',` @ C-O leyl
• Primary Owner(s):
Name(s): �S- n
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line: _( )
Email:
❑ Check 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: a 2Srl L4w&4C 51-1109-a-C N V2
Cell Phone:_( ) Land Line: _(� )
Email:
Contact Person for any questions regarding this project: c y !hAJ
Cell Phone: ( SO-) 'YqS ( 7( &. Land Line: ( g%P ) 7c/1 ®-s-e4
Email: Lit C(E�- 0
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 above::`
PRINT NAME: _Jo
SIGNATURE: DATE: 4 1 L
Fuel Burning Appliance&Chimney Application Revised December 2020
Y. THE
The Fireplace Company,Inc. Estimate
t
make Shore Drive �� , 0,COMPANY
Lake George,NY 12845 ,� Date 9/15/2021
Phone: (518) 668-9300 ,
Fax: (518) 668-9380 "We Keeplhe Home Fires Burning" Estimate# 9142
Customer Phone: 845-443-1766
Work/Cell:
John Kennedy Job Location: 34 Dorlon Drive
Queensbury,NY 12804
4ty .Item Description; Cost Total_
1 TI-98500143 Lopi Radiant Plus Medium Gas Fireplace Insert,GSB2 2,050.00 2,050.00T
1 TI-95200267 Universal II w/Barrier Screen&Drop Down Access 289.00 289.00T
Door
1 TI-96100553 Panels,One-Piece Large 151.00 15 LOOT
I TI-96100835 Brick Fireback for Radiant Medium 162.00 162.00T
1 TI-99000198 Universal Fan 253.00 253.00T
1 ST-1001-A On/Off Remote Skytech 154.00 154.00T
1 SDV-46DVA-CL33 Aluminum Co-Linear Liner Kit,3"x 3" 477.00 477.00T
TFCSH Palletized Shipping Fee 100.00 100.00T
TFCGE Gas Line&Electric Materials 265.00 265.00T
Appfok,1:5FVof CSST--(remove blackiron:and`.go
through:cleaaout in crawlspace).
Subtotal
Sales Tax (7.0%)
Total
Manufacturers are liable for the warranties on their products. Customers will be responsible for any costs
incurred above manufacturer's warranty reimbursement. We warranty our installations for 12 months from
the installation.invoice date.Customers are responsible for all building permits.
Payment to be made as follows: 50% Deposit -Balance Due Day of.Completion
Acceptance of Estimate-The above prices,specifications and
conditions are satisfactory and are hereby accepted. You are
authorized to do the work as specified. Authorized Signature:
Customer Signature: Date of Acceptance:
Note: This estimate may be withdrawn by us if not accepted within 30 days.
Special orders,fireplaces,stoves,stone and electrical parts are JKRuYnable and non-refundable. 25%restocking fee on returned items.
A.._.-..,... _!___.__ _f l Cn/ /r An/ inn, .rr• r r r .r, ,• .... -.-
THE
Company,Inc. FM ACIE Estimate
f-
Ae Shore Drive �� �� +off"paN''
.tee George,NY 12845 Date 9/15/2021
Phone: (518) 668-9300
.. "We KeepThe Home Fires Burning" . .- Estir>tate# 9142
Fax: (518)668-9380 - -
Customer Phone: 845-443-1766
Work/Coll:
John Kennedy Job Location: 34 Dorlon Drive
Queensbury,NY 12804
Qty Item Description C66t . Total
Need Bumpout Box and Raceway(almond)for Electric
•
TFCIALR Installation Labor
MUST;BRING;1%4 and 172 iece.of concrete btiard-
`' . _
;because of lowered firebox
**Remove Gas Logs**
*Bring 9x9 Cap;for Additional:$$Not Included in.this.
Estimate or Reuse 8x13 Currently Up Top on Fireplace
x
All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to
standard practices. This is an estimated proposal. Any alteration or deviation from above specifications and
discussed installation will be billed as time and material.It will become an extra charge over and above this
estimate. Deposit and payment arrangements areas specified below. Final payment is required on the day Subtotal $
of installation and any additional billing adjustments will be made on or after installation date. When usfng a
credit card for payment,you authorize its to charge the balance of this estimate the day of installation. All Sales Tax (7.0%) $
agreements contingent upon strikes,accidents or delays beyond our control Owner to carry f re,tornado and
other necessary insurance. Our workers are f lly covered by Workman's Compensation Insurance. Total $
Manufacturers are liable for the warranties on their products. Customers ivill be responsible far any costs
incurred above manufacturer's warranty reimbursement. We warranty our installations for 12 months from
the installation invoice date.Customers are responsible for all building permits
Payment to be made as follows: 50% Deposit -Balance Due Day of Completion
Acceptance of Estimate-The above prices,specifications and
conditions are satisfactory and are hereby accepted. You are
authorized to do the work as specified. Authorized Signature:
Customer Signature: Date of Acceptance:
Note: This estimate may be withdrawn by us if not accepted within 30 days.
Special orders,fireplaces,stoves,stone and electrical parts are n9arOl able and non-refundable. 25%restocking fee on returned items.