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1989-849 CERTIFICATE OF OCCUPANCY Y TOWN OF QUEENSBURY WARREN COUNTY, NEW YORK Date January 24 ig 91 This is to certify that work requested to be done as shown by Permit No. 89-849 has been completed. This structure may be occupied as a n addition t o dvelling i Location Route 149 Owner By Order Town Board TOWN OF QUEENSBURY I Director of Bldg. do Code Enforcement Inn , T ^ 1Tr '.iLtrfr. r � ! C; :t. Nn _ � 'JI `Et , P ' 2tisTT TOWN OF Q [..r'EE:tiSB L RY f, r' C:.l.}v e4f ` TTOWNOUEENSBURY EIVED 7 j9pq i;t? ILDING jVNo CODES:riY .end t(,turrtNn Roans RnOD nuE£NSBURY , NESJ YORK 1280a €�G�tTrt L t U ' Tel . ( 518 ) ? 92- 5d32 Ext 204 f F f * * � F A a'. F * I f ! f ! f t f f t f ■ F Y F • F f 1 ■ It, 3' E1r2? tIT hlUS'C DOOBTAINED LtEh' ORE LEC, INriING CC� hISTT�.UC:TICIIJ . NO INSPECTIONS VILL, Br MADE UNTIL APPLICANT [ iAS P.LCCIVED A V ,"4Lii} iiL' iLCkINC PERMIT * All appl icablo sPaces onTttktris application the mustrever be Os' c.•� sicic � ofn this eshcet . s' L3atule of the a >'P A {{e k Ys `,*,A� JACK !Vl '1' I1e owner of this property is . IEL . �� �]- �J � t L' . 4 . Address . 0 , 5 r „ter. (c?3 TAX MAP Noe �_/ [C7 i' r o p e r t y location �� [!•X2r..}F� � � l�4'�1 � ri+PsR- � Ilas there been any , plit of this property since October 1 , 1 `388 ? yes / no 1f yes , Planning Board Review is necessary * LOT NO SUBDIVISION NAME , IF APPLICABLE it- ne person responsible for supktrvrision of work as regards Building Codes is : - 0. c� Dy5 [ 1 � 1 )`y A l TEL NO NA Jet F }} P . O . ADDRL . 5 Tel � 3 - GO rtume of builder J +. q Address RC7• 13 r 201S Tel t4"me of Plumber 1.d.lress Tal n 1 br,1�J A J d r.a� 5 Nume of Maso C. IN10101ATION ( QXX` Ice use only ) . `GQNINC, OCSICNATICN OF PROPERTY _Conotructiorw of build36 "7 , pERMITTED ACCESSORY �Adaitian to a builaing PERMITTED PRINCIPAL A1. t .: r.,taon to .a LutIdLnq . REVIEW REQUIRCD PLANNING BOARD ZONING ROAR -� ( ,,Q Cl ,.iiu) u to exc � rfor d %-MQnLi4n:;] + SITE PLAN REVIEW # APPROVED DATE Uct,ur work t.1u_crtu.c } r VARIANCE p APPROVED DATE I ROBS AFtLA OV P ROP OS L D. "£ LtUCIF fcli . Remarks * lst floor 52. sq ft . 1 ' nd Floor I�J /A sq ft . C01•IPLLt' 1 SNk'OI.rM't'iC+N 14L"QU lct:f] ull4tii . A� lr y Q� ' •r Sir.a of i�rof,urcy X 1• e x �� o other Floors s, q fit Lx 1} ' i:. ci11ry L: .---uili1i1tgL10l SL :u �it7 � rc . ( not ccll :ar or bas .: manc ) TOTAL FLOOR AREA Sq ft * Lx ].:. Ca�tCj i7ut161 )�["V [ :. � Ua+: liwu csr' nGW t h L;tructuru 2'r f Z?a ft ` t 'u�s+ ,dation-piers ,l.iL+/Cr:awl/L�arti•..1/ full * I+rorsa;.oci buila� nq , r.ti� c:cn4 � crow f, raLaSr�ty 1Lft ( circle ano ) Front yard 61 �„� r_ t near yurd� Na . of s .oria . (jjabicablu :;I�afiel _ side y;ards� n ^t t and I� C7 LC 13c] it� ighc tyrada to rledclal �.f„ owbommoft . F If on cr,rnar , t0eClla`.:k from Sid" � trrLt rc Ii rai; id"ntial , no * of b"Zf:.milims �+ n NgpPy A ; : ,; llo . of rac.�ny fcxciudin�Nb� +i I • No . of bodroolas + PFt Y LUILDING No . ofbatltroow : �— Ono Cauchy dwelling L'rjuvAry 1ru.ACi.ruJ aay'r' 1: rul �-, --- + 11'+4500 t;�uLLly dw011iny Kults.saliis awulling / r+ulnbcsr of units No , of f7.rwpl .]t:uaa to lam an�t:.11ud� C7 - . ��drlA,anQ21v. occuriaurcy W& II :► Wuu.t stove tr.: ir�m:t::.11r. sl '�,C, ? + ouCUpar%c:y s i +i CvAnt .al Air col. itiun l.rcg? Business BU I LO I NG STYLE, Pp..2I mAAy STRUCTURE . Inctuscr ial Ocher 116rltC}t L'Criltwiui+4rrrry Lon C:.17in I t .ad.iitiun . Arl ,rit Will u :v fi+:'l ti.+ ix:.:d raancl% p{,;atlraic.�, i ul,lux + :alalic 1A0tvQl old sCylQ fJ/Ak Gcr�uc ' ACCESSORY UISILOINC- czar C d C4Ct;+tJ +: sae:eacriaeE yrr:+qC/ono cur/ two czar/ L'[,lonial scowl E'owl� dowse C.ar' Attiachui:1 cJ"r"gr•/orlr: Carp CWO ('.;,r/��,,,��„ ( cIIICL-L•' OWL: PLEALE 1 • ■ ■ a s a . ■ a ■ r a a a a a a + Vr .Lvuty Stt]r:a+� .3 kiuiiLling + ~'-Ocher l: S`. 'E' Il+tAR` 1: i7 mxkKEY` VVA� I or f v C1H .`a '1• k U C'r Iota IN[•'ORMATTON ON OUILOTHC spRcYFICATIONS . ON Ti.L'VCRSE !: Tor. OF TUTS ,111iF `P, 'I'O Be COl�tP41!'I'LLt ! Form DPA I0/88 vI i sells RUI '.3ING PERMIT APPLICA=.-'CN BUILDING SPECIFICATIONS : ±ype of construction , wood fra:r:e , moire safe , etc . � will any second-hand or ungraded lumber be used ? It moo , for wkat ? oundaLion wall material PWy2 Jr, ( � T*. ickness {,ALA Depth of foundation below grade ( to bottom of footing ) Will there be a cellar ? " D Heated or unheated ? � I~ � q f Floor sq . footage st Will there be a basemen= ?� p Will any portion be used as living space ? ( If so , what portion ? sq . ft . - - Type of use ? Type of roof - sloped/ flat/shed/other Hip waterial of roof Si �� Sk�rl��te�pe , wood studs 2 " x�-" spacinq [ C' _" o . c . length JC2 ^ft . .Toists ( floor beams ) 1st . floor X s a , 3oists [ floor beams ) 2nd . floor` A cinq O . C . span ft . ,:Iverlays ( ceiling beams ) } fi'1 * X - s spacing " o .O . C . span ft . Roof rafters pacing o . c , span ft . K spacing o . c . span ft . Roof trusses ( pre- engineered ) spacing " O . c . span ft . Exterior wall finish P0.0 Of what material ? E . C:'I_ CeAD�ki- Interior wall finish u A/1 �Zso If a garage is to be attached , describe materials to be used for FIRE SEPARATICN : Is there to be an opening between garage and dwelling ? If so will a Fire- rated door , enclosure , and self-closing device be provided ? Will a flue - lined chimney be installed? W Q Height above roof ft . Depth of chimney foundation below grade ft , Depth of fireplace hearth ft . in , � Water supply - Municipal {� or private well t'rtC 1>XAA. , SEPTIC SYSTEM distance from ANY private well ( including adjoining properties tilJjy ft . (A separate application is necessary for any repair or new installation of septic system ) D E L L .A R A T I 0 N 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, Signature caner, ne 's agent, architect , contractor' Ift It SPECIAL CONDITIONS OF THE PERMIT : By TrDWt4 jEw Wit; E �4j6 n . WARREN COUNTY , NEW YORK Application for ; BUILDING PERMIT IN CONSERVATION WITH THE NEW YORK STATE ENERGY A permit must be obtained before beginning work . ANSWER ALL of the following : 14 Gross floor area IS fim:mz- 2 . Type of heat � ,� � k-3 {' ► ] 4 G .c M rJc � =f �'s i�Cx ' �7 /a �� t - t- 3 . Is the building mechanically cooled ? q , percentage of area of windows and doors A . over 16 % Only 1 . Uo value of gross area of walls , roof / ceiling and floors exposed to ambient conditions 2 . Floor over heat - ? spaces YES No a , Are foundat an walls insulated ? YES NO le If YES . what is the R value ? 3 , Slab on grade YES NO a . If YES , wh . t is the R value of insulation around perimeter of floor ? 4 , Is basement heated ? YES NO a , R value of insulation - s * Type of insulation 8 . Under 16 • Only 1Tj ;:mm 1 . R value of roof and floors exposed to ambient conditions . 2 . R value of exterior walls 3 . R value of glazed area 4 . R value of doors c � � 5 , R value of floors over unheated spaces 6 . R value of slab edge insulation - unheated slab 70 R value of slab insulation - heated slab 8 . R value of heated basement / cellar walls ( above grade ) -Js 91 R value of heated basement / cellar walls ( below grade ) il 100 Type of insulation C �c3��' Cs �-► S� L /'"� ` `'" C> Kg '- Co controls 40 mmummum1 . Thermostat maximum heat setting 4r S i" �' r D . 16 Duct Systems 1 . Is duct system installed in unheated spaces ? YES a . If YES , R value of duct installations b . R value of duct in other areas- E . Piping Insulation 1 . Size of hot water or cooling carrying agent Pipe 2 . R value of pipe insulation F . Service ►later Heating 1J }�. I . Performance efficiency. 2 . Temperature control setting maximum kJ a Gm Far Swimmtin4 Pool Only 1 . Maximum heating Telephone No L� `� 3 — r.�,y C7 a plicant ' s signature ) TOWNOF ,QUEENSBURY BUILDING AND CODES DOPARTMENT BAY & HAVILAND ROADS ] 280 QUEENSBURY. NEW YORK ir TELEPHONE (5I8 ) 792- 5832 BUILDING INSPECTOR' S REPORT REQUEST R rNSPECTI CV RECEIVE 2 il� "'a -�- NAME �CATroN PERMIT # DATE APPROVED E YES NO FOOTING/PIE SiUR FORMS MONOLITHIC p_pROOFrNG FOUNDATION/D VAL BACKFILL APP ROUGH PLUMB, FRAMING —IN ELECTRICAL ROU i INSULATION= s FOUAIDATION ,FLOORS WALLS CEILING FINAL .INSPECTION: CHIMNEY HEIGHT ROOFING , SIDING _ EXTERNAL PORCHES/STEP STAIRS—CLEARANCE & RA F PLUMBING FIXTURES✓REL .INTERIOR TRIMIPRIVACY �OOR5_ �----- FINISHED FLOORS GARAGE FIREPROOFING DOOR CLOSERS) SMOKE DETECTORS FINAL ELECTRICAL INSPECTI�IN_��� .� FINAL APPROVAL OF CONSTRUCTION A SIGNED CERTIFICATE OF OCCUPANCY 3iENT BE OBTAINED FROM THE BUILDING DEPARTMENT BEFORE THESE PREMISES ARE OCCUPIED ! i I ' f REMARKS : ' I Ale { f{ I r INSPE TOR TOWN OF QUEENSBURY 41 r� ---- BUILDING AND CODES DEPARTMENT DAY & HAVXLAND ROADS QUEENSBURY, NEW YORK 1280J6 TELEPHONE (528) 792-5832 BUILDING INSPECTOR ' S REPORT REQUEST F V XNSPECfTXON RECEIVED.— NAME _^_J L L'[e.i�—� LOCATION l DATE Z _ lCJ PERMIT # APPROVED YES NO FOOTING/PTERS' MONOLITHIC PO FORMS FOUNDATION/DAM —PROOFING BACKFXLI. APPROV _ ROUGH PLUMBING L,' _NXNG ELECTRICAL ROU INSULATION: FOUNDATION FLOORS WALLS CETLXNG FINAL XNSPECTTON: CHIMNEY HEIGHT ROOFING SILTING EXTERNAL PORCHES/ TE STAIRS—CLEARANCE & RA PLUMBING FIXTURE /BELT VALVE INTERIOR TRIM/P IVACY D RS FINISHED FLOOR GARAGE` FIREPR FXNG DOOR CLOSER (S) SMOKE DETECTO S FINAL ELECTRIC INSPECTION FINAL APPROVAL OF CONSTRUCTION 0 A SIGNED CER FXCATE OF OCCUPANC MUST BE OBTAINED FRO THE BUILDING DEPAR ENT BEFORE THESE PREMXS S ARE OCCUPIED! REMARKS: I SPECTOR TOWN OF QUEENSBURY .BUILDING AND CODES DEPARTMENT BAY & HAVILAND ROADS QUEENSBURY, NEW YORK 12804" TELEPHONE ( 51.8) 792-5832 BUILDING INSPECTOR' S REPORT REQUEST FOR INSPECTI.ON RECEIVED I� r NAME I J LOCATION _ r 9 q DATE _ PERMIT ■ "~ � APPROVED ' YES NO FOOTING/.PIERS MONOLITHIC POUR FORMS FOUNDA"Y`ION/DAMP-PROOFING BACKFILL APPROVAL ROUGH PLUMBING FRAMING ELECTIRICAL ROUGH-IN INSULATION: FOUNDATION FLOORS WALLS CEILING INA.L INSPECTION: } CCHIMNEY HEIGHT , x ROOFING y SIDING EXTERNAL PORCHES/STEPS _ STAIRS-CLEARANCE & RAIL, L' PLUMBING FIXTURES/RELI VAL INTERIOR TRIM/PRIVACY IRS FINISHED FLOORS GARAGE FI]REPROOFING� DOOR CLOSER(S) ^- .... SMOKE DETECTORS FINAL ELECTRICAL INSPEC ON FINAL APPROVAL OF CONST UCTION OK TD ISSUE C/O OR C/C A SIGNED CERTIFICATE OF OCCUPANCY MUSTS OBTAINED FROM THE BUILDING DEPARTMENT BORE THESE PREMISES ARE OCCUPIED' {i REMARKS: 14214931 pEPA� �/_ -�= INSPECTOR ...�... National Headquarters 1337 VWIV Vllhi t6riPtki West Chisstdt,iPA 19380 '�W Cate: city, Town or Township �3{"�t` rvt�! ► f County—�3 p" ryC� State f Location/Address If Located in Rural Area - Please Attach Directions) Pole # Owner ir ,, 'Permiir # Occupied Ae ! � ��_ ' = d`17 • r Blii!'ding New ; Old © Occupant Work Area in Building 'Floor *, etc. ): A for: Wirin rvice 0 or: Ready for Ins ecti6n- Fee Remitted $ Cash 0 Check 0 q- . Male Pa abw to: M.D.I.A. _000. ,7 I000 12dQ L5 L750 2000 2250 2500 2750 3a00 - ,� Number of Rough Wiring Outlets Elect, Heat Switches Amp: Service Surface Unit Cishweer` ` Range Lighting Water.Heater Air Conditioner Dryer Pump Receptacles Oven Garbage Disposal Wiring and Controls for Burner Number of Fixtures Amp. Receptacles Fractional H.P. Vent Fans Other Equipment: MOTORS H.P. /- 1/32 1J10 1/a 1/6 1/4 1/3 1/2 3/4 1 11h 2 3 5 71h 10 15 20 25 30 40 50 75 11 Mark Number of Each Size Applicant's . Signature License # Permit T/A Utility (NAME) E LOCATION) Applicant's Address: (City) (State) (Zip) Service . Request # Phone #. _ Electrician:. 164-FTE'_RECEIVED; PATE INSPEL"YEb? ' `- ' Correct Location : Same as Above or : " Red Notice Label a Rough Wiring Outlets Surface Unit Oven Switches Range 4 r Garbage Di:lpos"al Receptacles Water Heater - Clijhwasher Fixtures Air Conditioner Dryer Amp. Service Equipment Burner, ri"Q& Comrdli for Amp. Receptacle Amp. Service Conductors Pump Vent Fans MOTORS H,P, 1/2U 1/12 1/l0 1J8 1/6 1/4 113 1/2 3/4 1112 2 3 5 7112 110 TS-7 25 40 1150 75 1 ' Mark Number of Each Size f � Elect. Heat Sao Asa 1000 1250 1s00 1750 a 225a 200 2.500 275a a00a 1. - i Q RW Progress : Inc. El LkOID Contractor CFT Violation : Work Comp. Inc. 0 CASH L/A Owner Fee cHiC # E3 L-/A Due MO # Q IPA Munir#pal . INV # {per{ Applica?lt I_l Date: Other.Side Q Utility + Qwner Cut in Card 0 Temp # Date U . y INSPIECT014S SIGNATURE 0 Final # Date APPLICATION FORM NO. 250 EL t/d8"` � . �. 90 TOWN OF QI.UEENSBURY BUILDING AND CODES DEPARTMENT / BAY & HAVILAND ROADS QUEENSBURY, NEW YORK 2280* TELEPHONE {518) 792-5832 BUILDING INSPECTOR ' S REPORT REQUEST FOR PECTTON R CETVED NAME - LOCATION 7` DATE PERMIT APPROVED FOOTINGfPIERS YES NO d'10NOLITHIC PO U FORMS I44FOUNDATTON/DAMP PROOPTNG BACKFILL APPROV L ROUGH PLUMBING FRAMING _ ELECTRICAL ROUGH IN INSULATTON: FOUNDATION r FLOORS WALLS f CETLTNG FINAL INSPECTIO2V: l CHIMNEY HEIGHT ROOFING SIDING EXTERNAL PORCHES/ST pS STATRS-CLEARANCE & XLS — PLUMBTNG FXXTURES/RE IE VALVE TNTERIOR TRIM/PRIVAC RS FINTSHED FLOORS ��-- GARAGE FIREPROOFING - DOOR CLOSER (S) x SMOKE DETECTORS FINAL ELECTRICAL INSP CT N FINAL APPROVAL OF CO STRU T'TON ~'- A SIGNED CER'TT. E OF OC PANCY MUST BE OBTAINED FROM THE BUILDING THESE PREMISES A E EPARTMENT BEFORE OCCUPIED. i INSP OR - TOWN OF QUEENSBURY BUILDING AND CODES DEPARTMENT BAY & HAVILAND ROADS QUEENSBURY, NEW YORK 1280& TELEPHONE (518) 792-5832 BUILDING INSPECTOR ' S REPORT �� REQUEST FOR INSPECTION RECEIVED NAME 4 LOCATION eo. r�l DATEF PERMIT ## APPROVED YES ' NO OOTING/PIERS MONOLITHIC POUR FORMS F UNDATION/DAMP—PROOFING ACKFILL APPROVAL ROUGH PLUMBING FRAMING ELECTRICAL. ROUGH—IN INSULATION: FOUNDATION FLOORS WALLS CEILING r FINAL INSPECTION: CHIMNEY HEIGHT ROOFING SIDING 1 EXTERNAL POR ESfSTEPSt STAIRS—CLEARANCE & RAI.L,45� PLUMBING FTAVTURES/RELIEF `: V� - AZVE INTERIOR IM/PRIVACY DOOP?S FINISHED L+OORS GARAGE F REPROOFING DOOR C SER (S) SMOKE TECTORS — 4S-rGD TRICAL INSPECTION OVAL OF CONSTRUCTION ERTIFICATE OF OCCUPANCY MU3ST BE OM THE' BUILDING DEPARTMENT BEFORE THESHIPREMISES ARE OCCUPIED! REMARKS: f � INSPECTOR TOWN OF QUEENSBURY BUILDING AND CODES DEPARTMENT BAY & , NE ROADS •' :� QL7EEIVSBURYBURY. NEW YC7RK 1280$ f�.'•"•' TELEPHONE (518) 792-5832 BUILDING INSPECTOR ' S REPORT REQUEST FOR INSPECTION RECEIVED NAME LOCATION DATE _e�� �_��_.. -_ PE•RMXT , APPROVED YES NO OTrNG/PIERS MONOLITHIC POUR FORMS FOUNDATION/DAMP-PROOFING BACKFrLL APPROVAL ROUGH PLUMBING FRAMING ELECTRICAL ROUGH-rN rNSULATrON: FOUNDATION FLOORS WALLS CEILING FINAL IIVSPECTrON: CHIMNEY HEIGHT ROOFING SrDING EXTERNAL PORCHES/S'rEPS STAIRS-CLEARANCE RArLS PLUhIBXNG FIXTUR '/RELIEF VALV INTERIOR TRrMf X VACY DOORS PXNrSHED FLOG GARAGE FIREP FING - DOOR CLOSER (0) SMOKE DETEC RS FINAL E'LECTR,r`CAL INSPECTION FINAL APPROVAL OF CONSTRUCTrON A SIGNED CFiRTrFXCATE OF OCCUPANCY MUST BE OBTAINED FROM THE BUILDING DEPARTMENT BEFORE THESE PREMXS.ES ARE OCCUPXEDI RHMARKS: INSPECTOR - TOWN OF QUEENSBURY �} BUILDING AND CODES DEPARTMENT BAY B HAVILAND ROADS QUEENSBURY, NEW YORK 12809- TELEPHONE (518) 792-5832 BUILDING INSPECTOR ' S REPORT REQUEST INSPECTION RECEIVED NAME LOCATSO DATE PERMIT # APPROVED YES NO T/AOOTING/PIk'RS MONfJLITHIC POr] FORMS_ FOUNDATTONI=P PROOF2N(; BACKFILL APPROy ROUGH PZUMB.TNG FRAMING ELECTRICAL, ROUGH- INSUZ ATIONr FOUNDATION FLOORS WALLS CEILING FINAL INSPECTION: CHIMNEY HEIGHT ROOFING .SIDING EXTERNAL PORCHE /STEPS STAIRS-CLEARAN & RAILS PLUMBING FIX ES/RELIEF VALVE INTERIOR TR-rN PRIVACY DOORS FINISHED F S GARAGE FIRED OOFING - DOOR CLOSER ) SMOKE DETEC RS FINAL ELECTFt AL INSPECTION FINAL APPROV L OF CONSTRUCT?ON a A SIGNED CERT-rPT ATE OF OCCUPANCY MUST BE OBTAINED FROM THE BUILDING DEPARTMENT BEFORE THESE PREMISES ARE OCCUPIED! REMARKS: INSPECTOR THE NEW YORK BOARD OF FIRE UNDERWRITERS CERTIFICATE NO DO NOT WRITE HERE - FOR OFFICE USE ONLY S U I LDI NO PERMIT NO. TEMP # DATE CeTV UHVILLAGE +/ : TOWNSHIP OOUNTY STREEET AND NQ. OR RCMD - \ t � POLE NUMBER BEIWEEN WHAT TWO CROSS STREETS IS PREMISES LOCATED? SECTION BLOCK OGGUPANi'S NAME +..� L _,,yv i 8uI4 DING 1pCCUPAN.� OWNERGS NAME HOME TELEPHONE NUMBER G URRENT SUPVLIED BY I �' . AFROM THEIR y4FFICE ,,r I^.'ORK TELEPHONE NUMBER NEW �. I - i WORK IS NEW ADDITIONAL LIST BEL bEFEGTH REMOVED 17 OW ALL EQUIPMENT WHICH YOU INSTALLED Loca• NUMBER OF OUTLETS No" Of Fixtures $. tion Lamp Receptacles MOTORS HEATERS BRANCH OFFICE USE Ceiling Side Artach't CIRCUITS ONLY WWI RecepTs Swich Peodanl Brackc4 Na, Type Each No. Watts No. A.W.G. OUT- Each Gauge INSPECTION SIDE SUB- RASE BASE- MENT Isl FL 2nd FL 3rd FL- REMARKS: LIST OTHER ELECTRICAL DEVICES NOT SET FORTH A13O+4E. THIS APPLICATION IS INTENDED TO COVER THE ABOVE-LISTED EQUIPMENT TO BE INSPECTED, BUT IF AT TIME OF INSPECTION, THERE IS FOUND ADDITIONAL EQUIPMENT NOT ABOVE LISTED, YOU ARE AUTHORIZED TO MAKE THE INSPECTION AND ADJUST THE FEE TO COVER THE ADDITIONAL EQUIPMENT, AS PROVIDED BY THE APPLICANT SIZE OF MAINS FEEDERS ELEK,TNIG SIGNSAAM PS TOTAL WAITS CHAHACI'ER OF WO Rk EXPOSED GA: TUBE SIGNf NSFORMERS OF BATE WURK TO BE STARTED L] GONCEALEp tM DATE COMPLETED SIZE OF SIGN (NUMBER) SERVICE ENTERS BUJLDIriG CAPACITY IMANUFACTUREH OF SIGN DATE INSPECTION REQUESTED ON (OR AS NEAR A OVERHEAD El UNDERGROUND S POSSIBLE) MUST ENTER APPLICANTS AVOID AEI-AYS BY GIVING FULL AND ACCURATE I I - ATION. ALL IDENTIFICATION R PRINT NAME AND ADDRESS MUST- BE LLEDIN OR APPLICATI N W1Y BE R ETURNIED.� NAME pF APPLICANT DATE OF APPLICATION Tt1RE OF APPLICAW e . $TAFFY ADORE$$Y _ �' 0 `a �,. '• I I„:' :., 'e ;� TELEPHONE NO - CITv OR POST OFFJCE f 2JP CODE .t LICENSE CIO WHEN APPLICABLE :.I 85 Jahn Street E-,I 41 State Street L7 570 Delaware Avenue �1 NEW YORK, NY 10038 ALBANY, NY 12207 BUFFALO, NY 14202 217 La ke Avenue C] 202 Arterial Road ROCHESTER, NY 14608 + SYRACUSE. NY 13206 THE NEW YORK BOARD OF FIRE UNDERWRITERS