2011-139 TOWN OF QUEENSBURY
i
w 742
� � Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development - Building & Codes (518) 761-8256
CERTIFICATE OF OCCUPANCY
Permit Number: P20110139 Date Issued: Tuesday, May 10, 2011
This is to certify that work requested to be done as shown by Permit Number P20110139
has been completed.
Location: 200 LUZERNE Rd
Tax Map Number: 523400-309-009-0002-001-000-0000
Owner: HOMESTEAD VILLAGE L P
Applicant: MIKE & HEIDI CALE
This structure may be occupied as a:
Mobile Home In Park By Order of Town Board
TOWN OF QUEENSBURY
f I
Issuance of this Certificate of Occupancy DOES NOT relieve the /
/ � r� '
property owner of the responsibility for compliance with Site Plan,
Variance, or other issues and conditions as a result of approvals by the Director of Building&Code Enforcement
Planning Board or Zoning Board of Appeals.
TOWN OF QUEENSBURY
ellaki
$.0,41 742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building&Codes (518)761-8256
BUILDING PERMIT
Permit Number: P20110139 Application Number: A20110139
Tax Map No: 523400-309-009-0002-001-000-0000
Permission is hereby granted to: HOMESTEAD VILLAGE L P
For property located at 200 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: HOMESTEAD VILLAGE L P Mobile Home In Park $15,000.00
4294 ROUTE 5 Total Value
CALEDONIA,NY 14423 $15,000.00
Contractor or Builder's Name/Address Electrical Inspection Agency
Plans&Specifications
2011-139
105 Alpine Ave-980 sq ft mobile home in park-Mike&Heidi Cale
$117.60 PERMIT FEE PAID-THIS PERMIT EXPIRES: Sunday,April 22,2012
(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 To of- ens ; !Q ~d•1# A_ s it 22,2011
SIGNED BY -44
for the Town of Queensbury.
Director of Building&Code Enforcement
C 7-2OFFICE USE ONLY Y .-_• I
TAX MAP NO. ERMIT NO. / f / . ) DATE ISSUED:
LG '
:;!'/
PERMIT FEE / 7 APPROVALS: ZONING TOWN CLERK
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 Information Property Owner Information
Name: 7/�i(r ..z /�%��/ L4�-�- Name:
Address:2071/0_c /44e c ,cU�9 ..L Address: /4.) . .44/4a.—
l
� i c ,2 �6'L
Phone No. / ' J��22 7 Phone No.
Parcel Information
Proposed Date of Placement: Property Location:
Road,Street,Avenue
Name of Mobile Home Park: (if applicable) Tax Map Number:
Mobile Home Information Zoning Information
Approximate Value of Home: $ ii/00 Zoning Classification:
New Home: Yes (I c Size of Property: 5-7 ft. by/20 ft.
Replacement Home: Yes Existing buildings: ,,e;t
Size of Mobile Home: /'Q ft. by 70 ft. Setbacks: front yard ZD ft. rear yard / .' ft.
l/ side yards /G ft. and , O ft.
Singlewide: )( Doublewide:
Number of Rooms: (exclude baths) Accessory Building(s): circle
Number of Bedrooms:
Number of Bathrooms: Detached garage: 1-car 2-car car
Circle: Gas Fireplace/Woodstove/Wood Fireplace Attached garage: 1-car 2-car car
Foundation Support: Storage building: Yes No
Type Size & Depth Other:
Piers /
Water Supply: well dr municipal
Runners
• Slab Is Septic Permit Required? Yes or No
Continued on page 2
etTown of Queensbury- Community Development Office - 742 Bay Road, Queensbury, NY 12804
Revised March 2010
Name of Installer or Mobile Home Dealer:
Address: Phone:
Complete information below found on a "Plate" or"Sticker"which is affixed to the mobile home:
✓ Insignia serial number: 7/‘ — 0/3--6 &
✓ Name of manufacturer: 5"t/
✓ Plan Approval Number:
✓ Model or Component Designation: /777
(New home only)
/ Date of Manufacture:
Fr.:-.rc-.tu-.cus:-Yc-.c:rrrcu-xtu--csr::uuu-.�:.--.:u::ustuuuuu:r•.+.:cu:rc-.::c:cuuuu:::.Eu::•.cu:rrcuu-xzu:cusrrt:a.::._c:tu
AFFIDAVIT
Town of Queensbury State of New York
S County of Warren
,
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.
Installer Warranty will be provided at time of Certificate f Occupancy.
Signature: //2/_,Gt _
Owner, Owne ' Agent, rchitect, Contractor
f
dere:ue:s:s:er•�er_r»rtsuue.-•�•»-!:sr!:srss!s•_:u!:•..--sar!::r:s!:•»-::!:s;uuue:!:e:s::r!2!rtrtit:l::rtrw'S:li•.rSiLJL'tr•.:trSrt:Sf!tKS+'l:S.�:SA+Si{
SPECIAL CONDITIONS OF PERMIT
By:
Code Enforcement Officer
a1;1 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/p Depart-\2 am/pm
Date Inspection request receiv-': Inspector's Initials:
NAME: _ �1_ PERMIT#. ( /
LOCATION: C% �►I L�� DATE: $ `. //.
Manufactured Home
Modular Home
Footings_ Foundation Backfill— Framing_
Comments:
Yes No NIA
Foundation support,pier spacing,
Per manufacturer
Anchoring per manufacturer 2'from ends
Water line shut off
Sewer line support @ 4 feet
Heating Crossover[doublewide}off grd.
Dryer vented outside
Skirting ventilated 1 sa.ft.per 1,500 sv.ft.
Hot water relief valve piping outside
Deck,porches,steps,railing
Fumace/hot water operating
Garage Fire proofing
Fire Door/Door closers
Plumbing Fixture/3"Vent through roof[Modular] A-17,v F-19
o_...•tion insulation[if applicable] j. LC �
Smoke Carbon Monoxide Detectors/Interconnect
Final Electrical � ���V
Variance required
Data Plate okay
Manufactured HUD seal okay
Warranty Seal after January 1,2006
Installers Warranty Seal
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 CIO[Temp./Perm.] ‘./
Model# Serial#
Manufacturer
Date of Manufacturer
L:1Pam Whiting120101Building Codes Forms\Manufactured Modular Final Inspection 03 04 10.doc
Ckeri. , .) -- 41PrrN
Queensbury Building & Code Enforcement— Manufactured / Modular Final Inspection
Office No. (518) 761-8256 S l7/ a-Oii Arrive: am/p2_14...455art: ` am/pm
Date Inspection request received: Inspector's Initials:
NAME: 13al d& S!'e v PERMIT#: OC O// -/39
LOCATION: /& 5 i ne.. --r-. DATE: s7/ ii
Manufactured Home
X...
Hr& 4i 4 dr de-
Modular HomeBictce 02620— 44-o .'
(D
Footings Foundation_ Backfill Framing �L� / '
veLf ? -, 76 — 0`S
Co ments:
_Yes No N/A
Foundation support,pier spacing, /
Per manufacturer ,,�///
Anchoring manufaiurer rom ends .1- •�, r-" v
Water line sRa V � ' �
Sewer line support @ 4 feet ,/ /
Heating Crossover[doublewide}off grd. v J
Dryer vented outside
Skirting ventilated 1 sq.ft.per 1,500 sq.ft.
Hot water relief valve piping outside ` `
Deck, porches,steps,railing Yf
Fumace/hot water operating
Garage Fire proofing
Fire Door I Door closers11/
Plumbing Fixture/3"Vent through roof[Modular]
Foundation insulation[if applicable] ✓ �_
Smoke I Carbon Monoxide Detectors I Interconnected
.wt-._ 51‘"14-3-6'4
LO
Final Electrical ` L ` "`- ,
Variance required / / y y� p�J.� u5Data Plate okay `�L"
Manufactured HUD seal okay e '
/
Warranty Seal after January 1,2006 V
Installers Warranty SealI ' I/
18"x 24"access or 22"x 30"attic access
Vapor retarder under home 6 mil poly or other V
911 Street number V�
Okay to issue4tit).,
CIC or CIO[Temp.-/Perm_] �—
Model# Serial# 6 6l c —o 1 Cci
t Lt 1 �
Manufacturer4,A ��
J.� CrA
Date of Manufacturer ' j (�' f -` 0 "2t 'Y. ?)
L:lPam Whiting12010kBuilding Codes FormsWanufactured_Modular?sinal Inspection_03 04 10.doc
F
INSTALL NO. 15057 STATE OF NEW YORK
DEPARTMENT OF STATE
. et . ONE COMMERCE PLAZA ,/,1
I''-'`'11 99 WASHINGTON AVENUE 1
• ALBANY,NY 12231
INSTALLER'S WARRANTY SEAL
THIS SEAL REMAINS THE PROPERTY OF THE DEPARTMENT OF STATE
❑ NEW MANUFACTURED(HUD CODE) TI RELOCATED MANUFACTURED(HUD CODE)
A. Manufacturer's name: '/j//1>7 e
B. HUD label number: _ _ _ _, , Serial number: 6. //a-0/56 +Q
C. Retailer's name: Y ak..B J ,p/rJ es
D. Retailer's address: -'Cf,? / 7 f/-/ .w4rlrpc,/C `V7" 42 e--..z
E. Retailer's certification#: l r Q Q Q Telephone#:.S/e -77 %2-'
F. Installer's name: ,51--tfe Q gyp- 7 rii
r
�f .,[
G. Installer's address: ./..5V,„? /t 7 /`'or . / / 4f t �� 442 e?-2,r?
H. Installer's certification#: //N T-00/15/ _Telephone#:-C/S) 772-A2/`2.4,1<te
I. Date installed:-_ 'a // Municipality issuing building permit: Ue e_ns • t
/ / rn (City o Vi age)
J. Customer name
'and physical address (911)where home is insst'alled:,Z CAQPJ' /ql• e
/O$ /-A/pIre / Ikee 421yeer sfa. 2 ,New York. 42eaV
r �
By attaching this SEAL to this manufactured home,the undersigned Installer of this manufactured home warrants as follows:
I. 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: [//`7 /7
Signature of Installer or � ��JJ
r�lil �C.7ft�i�
Limited Installer:
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-1680(Rev.03/09)
Yellow Copy—Department of State White Copy—Retain for Your Records Goldenrod Copy—Permitting Agency Seal—Affix to Home
From:Helene Wendolovske At TD Insurance Agency Fa(ID:TD INSURANCE To:Inc.dba VMH Affordable Date:6/17/2010 11:42 AM Page:4 of 5
STATE OF NEW YORK
WORKERS'COMPENSATION BOARD
CERTIFICATE OF INSURANCE COVERAGE UNDER THE NYS DISABILITY BENEFITS LAW
PAR_ completed T 1. To be compld by Disability Benefits Carrier or Licensed Insurance Agent of that Carrier
• I a. Legal Name and Address of Insured(Use street address only) I b.Business Telephone Number of Insured
VALUED MANUFACTURING
HOUSING INC DBA VMH AFFORDABLE lc.NYS Unemployment Insurance Employer Registration
1572 RTE 9 Number of Insured 0694636
FORT EDWARD,NY 12828
Id.Federal Employer identification Number of Insured or
Social Security Number 331033484
•
2. Name and Address of the Entity Requesting Proof of 3a.Name of Insurance Carrier
Coverage(Entity Being Listed as the Certificate Holder) National Benefit Ute Insurance Company
WARREN COUNTY 3b.Policy Number of entity listed in box"la":
1340 STATE ROUTE 9
LAKE GEORGE, NY 12845 08910-0191416
3c.Policy effective period:
06115110 to 06115/11
{ 1
4.Policy covers:
a.0, Ali of the employer's employees eligible under the New York Disability Benefits Law
b.D Only the following class or classes of the employer's employees:
Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above
and that the named insured has NYS Disability Benefits insurance
er�veraY as des d above,
,
Date Signed 06/15/10 BY `Uhl
(Signature of insurance minces authorized representative or NYS Licensed insurance Agent of that insurance carrier)
Telephone Number 800.535-2711 Title Vice President
IMPORTANT: If box"4a'is checked.act this form is signed by the insurance carrier's authorized representative or NYS I.icer.aed insurance Agent of that
•carrier,this certificate is COMPLETE. Mail it directly to the certificate holder.
If box"4b'is checked.this eertil icate is NOT COMPLETE for purposes of Section 220,Sulxl S of the Disability Benefits Law It must Lx:mailed for
completion to the Workers'Compensation Board,DB Plans Acceptance Unit,20'kirk Stoat,Albany,New York 12207
PART 2.To be completed by NYS Workers'Compensation Board(Only if box"4b"of Part 1 has been checked)
State Of New York
Workers'Compensation Board
According to information maintained by the NYS Workers'Compensation hoard,the above-numed employer hits complied with the NYS
Disability Benefits Law with respect to all of hisiher employees.
Date Signed By�... (Signature of NYS Workers'Compensation Board Employee)
Telephone Number Title
Please Note:Only insurance carriers licensed to write NYS disability benefits insurance policies and NYS licensed insurance agents of
those insurance carriers are authorized to issue Fonts DB-120.1. Insurance brokers are NOT authorized to issue this form.
D13-l20,l(5-06)
H0 l ' I E T .L , GE TOWN OF QUEENSBURY
BUILDING DEPARTMENT
Based on our limited examination,compliance
with our comments shall not be construed as •
-•• • •• --- - -'- —-• ' •• • ------indicati•3 ••- •lams and s t-cifications-are in
_.. •T .. L. co p iam - wi' I : :u •• Codes or •
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"I have seen or :):Jserved, or believe I saw evidence of,
Frani.' o?U �� all objects :'ogles; wells, :ees ;erre etc.,
;: eS,
i shown ;;ri I also represent tti ;: have
LQ Applicant:Ail/<// e/ (--/Ate5:: / /4 p ,r. the distances set `:rte on the diagram."
Location: ,0S A/pig Avg �*u=
P6- ' (5 0 Homestead Mobile Home Park ez --_)�
Si i�AWRE I AI —
J HfY—V_ID X1'11 1J:3t rom: uu5 LUUtS J11:54231:3440 f t 0:'1`77 f 7CJOYJO rage•1'4
(i—
CODES
vtvisioN New York State Department of State Manufactured Housing Unit
DIVISION OF One Commerce Plaza, Suite 1160
CODE ENFORCEMENT 99 Washington Ave.
Albany, NY 12231
gADMINISTRATION 518.474A073 phone
DEPARTMENT OF STATE 55 518.486.4487 fax
. _._:: -•.__: .cv-:.:.. -.: , ......_..-,... •;__"'._....:i m.:..:u:�..- .'.31ti=7.:.7L�"L�=.cn �s'-�u u t i �•ti.}- r ITi _ - - _-__
Certification as a Retailer
of Manufactured Homes
Certification Number: 1RET0040
Effective Date: 11/5/2010
Expiration Date: 11/5/2012 •
Be it known that pursuant to the provisions of Article 21-B of the Executive Law and Part 1210 of Title
19 of the New York Codes, Rules and Regulations,
Valued Manufactured Housing, Inc.,
a business entity (viz.,a corporation ❑ limited liability company n limited partnership
Egeneral partnership (1 other [specify: ]) having its principal place of business at 1572 Rt. 9, Fort
Edward,NY 12828, (the"Certificate Holder") is a duly certified Retailer of Manufactured Homes.
This Certification is effective for the Retail Sales Location located at: 1572 Rt. 9,Fort Edward,NY
12828.
This Certification is effective on the Effective Date indicated above and, unless earlier suspended or
revoked, this Certification ceases to be effective on the Expiration Date indicated above.
NOTE: A business entity certified by the Department of State as a Retailer shall, at all times such certification
remains in effect, employ at least one person who is certified by the Department of State as a Retailer.
Employment of a person holding a limited certification as a Retailer shall be deemed to satisfy this requirement.
New York State Department of State
By:
Ronald E. Piester, R.A.,
Special Deputy Secretary of State and
Director, Division of Code Enforcement and
Administration
important:Display this document as proof of your qualifications to operate
at the above certification level.
11 \Ys\MOS:s raT