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1987-138CERTIFICATE OF OCCUPANCY TOWN OF QUEENSBURY WARREN COUNTY, NEW YORK Date June 16 19 ~ ~ This is to certify that work requested to be done as shown by Permit No. 87-133 has been completed. This structure may be occupied as a 7 Unit Motel Location west side Route 9 south of Route 149 Owner French Mountain Motel (L. Thomas Warner) By Order Town Board TOWN OF QUEENSBURY ,, Building b Zoning Impactor BUILDING PERMIT TOWN OF QUEENSBURY No. 87-138 WARREN COUNTY, NEW YORK PERMISSION is hereby granted to French Mountain Motel (L. Thomas Warner) o G D OWNER of property located at west side Route 9 south of Route 149 Street, Road or Ave. rt w in the Town of Queensbury,To Construct or place a 7 Unit Motel Building at the above location in accordance to application together with plot plans and other information hereto filed and 0rt approved and in compliance with the Town of Queensbury Building and Zoning Ordinance. rP 1. OWNER'S Address is RR #1 r Lake George, New York y 0 >v 2. CONTRACTOR or BUILDER'S Name Lew Casella n rD n 3. CONTRACTOR or BUILDER'S Address E (D 4. ARCHITECT'S Name rt W FJ- 5. ARCHITECT'S Address m 6. TYPE of Construction—(Please indicate by X) 0 rt (X)Wood Frame ( ) Masonry ( )Steel ( 1 Z, 0 �n 7. PLANS and Specifications ,tid 0 r_ No. 50'x26' per plot plan, specifications and application submitted rt m including sewage system. r 8. Proposed Use �o 7 Unit Motel Building V $5.00 C/O N• $ 100.00 PERMIT FEE PAID —THIS PERMIT EXPIRES November 1 1987 rt (If a longer period is required an application for an extension must be made to the Building and Zoning inspector of the 0 town of Queensbury before the expiration date.) rt tD N Dated at the Town of Queensbury this loth Day of April 19 87 C w r a SIGNED BY Q4 for the Town of Queensbury FJ Building and Zoning Inspector 0 TO BE COMPLETED BY BLDG. DEPT. Jotun o~ Queensbur~ BUILDING and ZONING DEPARTMENT Bay and Haviland Road, R.D. 1 Box 98 Queensbury, New York 12801 3~ ~ /~- ~ 3 APPLICATION FOR Application No. Permit Issued Permit Expires Zoning Designati~~ Variance No. Site Plan Review No. Approved by: 19 19 ~rrvrv o~ Qu~r~s+~u~}~ a'~C~C~~d~p MAR 3 4198 B/UIL,pDING 8c CODE DEPT. /J U ~v''``~ `~ /U~'U~ /~ / ~~~ n n FUILDINr AND ZONING PERMIT l _ ~~ ~~~ .:__ A PERMIT MUST BE OBTAINED BEFORE BEGINNING CONSTRUCTION. ANSWER ALL OF THE FOLLOWING. The undersigned hereby applies for a Building Permit to do the following work which will be done in accordance with the description, plans and specifications submitted, and such special conditions as may be indicated on the Permit. ---------------------------------------------------------------------------------------------- The owner of this property is: ~ T~,pu1c~S y~+c~~-N~ P. O. Address13x 3~-Ury~~3 ~~~ ~._a~~~~ C~~r~V~~~2_ Tel. '~~? ~ ~ ~ yJ.,P Property Location: /~C't ~ Tax Map No. / / Street number or building lot number Subdivision name (if applicable) THE PERSON RESPONSIBLE FOR SUPERVISION OF WORK AS REGARDS BUILDING CODES IS: Name P.O. Address Tel. No. Name of builder CAS-e-~~ ~ ~~~-~-`~ Address ~ S91~, Tel. Name of plumber -~zrol: F- ~~-~ ~w Address ) _ on( I .S Tel. '7Y ~ 9~J17 Name of mason ~ ~-~ ©~,,.,_~_ ~ Address ~ r~ ~~ i .~ Tel . 6 ~! a. 1 wC. NATURE OF PROPOSED WORK: * ZONING INFORMATION: ' Construction of a new building * A PLOT PLAN MUST BE PREPARED AND SUBMITTED, _ Addition to a building * drawn reasonably to scale and attached hereto, _ Alteration to a building * showing clearly and distinctly all buildings, (no change to exterior dimensions) * whether existing or proposed and indicate all Other work (describe) * set-back dimensions from property lines. Give * street and number or lot number and indicate ~ whether interior or corner lot. Show location FOR DEMOLITION PERMIT, STATE SIZE AND of water supply and location and configuration LOCATION OF STRUCTURES AFFECTED. * of septic disposal area. * * COMPLETE INFORMATION REQUIRED BELOW. * /~~ ft X ?~~ ft f i . property ze o S * ft X ft ) Si ildi i i b ( . ze s Ex st ng u ng * PROPOSED BUILDING AND USE: * Existing building(s) Use ~ v Size of new structure •Sv ft X 2 ~, ft * Foundation-pier/slab craw /partial/full * Proposed building, distance from property line (circle one) e ' ~ * Front yard °~. CSC ft Rear yard r,1_ / ft ) No. of stories (habitable spac -- * Side yards ~ ft and ~~~ L~ ft Height (grade to ridge) '2.~.. ft. If on corner, setback from side street ft If residential, no. of families * No. of rooms excluding baths) * , OCCUPANCY INFORMATION No. of bedrooms *• PRIMARY BUILDING - No. of bathrooms - x One family dwelling Primary heating system ~ Two family dwelling Type of fuel * •~Iultiple dwelling / Number of units 7 No. of fireplaces to be instaliezi. * Will a wood stove be installed? * Permanent occupancy Central Air conditioning? * Transient occupancy * „Bfsiness BUILDING STYLE, PRIMARY STRUCTURE * Industrial ~et ~ a~ Ranch Contemporary Log cabin * If addition, what will use be? Raised ranch Mansion Duplex ~. * Split level Old style B aloes Cape Cod Cottage hem * ACCESSORY BUILDING- Colonial Row Town House * Detached garage/one car/ two car/ car ( CIRCLE ONE PLEASE ) * Attached garage/one car/ two car/ car * * * * * * * * * * * * * * * * * * Private storage building _..... . ESTIMATED MARKET VALUE OF * Other CONSTRUCTION $ •71-tjZJ~' INFORMATION ON BUILDING SPECIFICATIONS, ON REVERSE SIDE OF THIS SHEET, TO BE COMPLETED! Form BPA 4/86 and-vl BUILDING PERMIT APPLICATION CONTINUED - BUILDING SPECIFICATIONS: ,Type of construction, wood frame, fire safe etc. ~ G~ Will any second-hand or ungraded lumber be used? If so, for what? /l(C++ Foundation wall material CCG ~kC.K~" Thickness ~ ~~ Depth of foundation below g~r~dee (tobottom of foot"`i~ng) Will there be a cellar? ~-'~° heated or unheated? r~V Floor sq. footage ~3uU sq ft Will there be a basement? ~~(6 Will any portion be used as living space? ~C~ (If so, what portion? sq. ft. - - Typq, of use? ~~ (,t ~.rc. Type of roof - sloped/flat/shed/other C Material of roof Size, wood studs ~--"X~" spacing l "o.c. length ~ ft. ,, Joists (floor beams) 1st. floor ~"X 1/) spacing "o.c. span j'~~ ft. Joists floor beams) 2nd. floor _~"X i -" spacing"o.c, span~ft. Overlays ceiling beams) "X spacing "o.c. span ft. Roof rafters "X spacing o.c. span ft. Roof trusses(pre-engineered) pacing~~"o.c. span ft. Exterior wall finish ( f t material? Interior wall finish p;~ r~ ~a, ~ If a garage is to be attached, describe materials to be used for FIRE SEPARATION: ~(~,~~,., 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? `~ Height above roof ft. Depth of chimney foundation below grade. t. Depth of fireplace hearth ~-----_~ in. Water supply - Municipal or private well JVIu NiCi~ SEPTIC SYSTEM _ Distance from ANY private well(including adjoining properties ft. (A separate application is necessary for any repair or new installation of septic system) Town of Queensbury A F F I D A V I T STATE OF NEW YORK 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. SWORN TO BEFORE ME THIS Signature _ ~~ Owner, owner's agent,architect,contractor day of 19 Notary Public, Warren County, N.Y. SPECIAL CONDITIONS OF THE PERMIT: By --------------------------------------- TOWN OF QUEENSBURY WARREN COUNTY, NEW YORK Application for: BUILDING PERMIT IN COMPLIANCE WITH THE NEW YORK STATE ENERGY CONSERVATION CODE A permit must be obtained before beginning work. ANSWER ALL of the following: 1. Gross floor area tt ~'6 ~~ ~~ 2. Type of heat ~1~'-cX`rt~-- 3. Is the building mechanically cooled? ~~~ S 4. 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 heated spaces YES NO a. Are foundation walls insulated? YES NO 1. If YES, what is the R value? G> 3. Slab on grade YES NO a. If YES, what is the R value of insulation around perimeter of floor? 4. Is ]mss-ement heated? YES+, a. R value of insula~e~ 5. Type of insulation B. Und er 16~ Only 1. R value of roof and floors exposed to ambient conditio ns- ~! 2. R value of exterior walls .°~ 3. R value of glazed area, ~ 4. R value of doors ~J ~~ 5. R value of floors over unheated spaces 6. R value of slab edge insulation - unheated slab 7. R value of slab insulation - heated slab 8 R value of heated basement/cellar walls (above grade) 2' . d ) ~ ~~~~ 9. R value of e heated basement/cellar walls (below gra 10. Type of insulation ~/J~-~,~/ 5~~~+ C. Controls 1. Thermos tat maximum heat setting D. E. F. G. Duct Systems 1. Is duct system installed in unheated spaces? YES NO a. If YES, R value of duct installation "-' b. R value of duct in other areas Piping Insulation /i 1. Size of hot water or cooling carrying agent pipe '" `~S~_ 2. R value of pipe insulation Service Water Heating y ~~e-~o 1. Performance efficiency 2. Temperature control setting maximum ~ ly0' For Swimming Pool Only 1. Maximum heating ~ Telephone No. ~"I ~\ s / C~~ signature) ~~~~ APPLICATION FOR SEPTIC DISPOSAL PERMIT DATE / LOCATION OF PROPERTY FOR INSTALLATION ~~~ ~°~'] ~~~ a Owner's Name: ~ ~~~A~S W c~ v'N'J'~ Telephone: ^] ~'( 01. Ski CJ~ Address: _~~ LlU x ~j~-~-~ Installer's Name: e~l~,"~~'~ Telephone: '' ~1 ~ ~ 3 ~ ~/ ~ Number of bedrooms (residential only) ~~ Total daily flow (compute @ 150 gal per bedroom) Topography: circle one: Flat Rolling Steep Slope Soil Nature: circle one: Sand Loam Clay Other of slope _~~°_ Ground Water: At what depth? ~ ( /~ ~ feet / Depth: feet Sc.~µ~ W~nev-~~vi ~~f'hs sys ~~ N~c~~1^', Wye-~Gt ~ka`C iK6~ IS uaYt~S Bedrock or Impervious Material: At what depth? _ ~! n,~ feet Percolation test: circle one: not required required /rate Domestic water supply: circle one: Municipa Well Other IF domestic water supply is a Well: Separation: Watersupply from Septic absorption _ 2~/, ~~ min. inch. feet PROPOSED SYSTEM: Septic Tank b9~' _ gal. (minimum size: 1,000 gal.) TILE FIELD: Each Trench feet /Total system length ~ ~/y feet SEEPAGE PIT(5): Number of ti / Size each 8 feet by .,j feet Size of stone to be used # - /Depth or Thickness - feet ***************************s#************ IMPORTANT ...Please...LIST NEW EQUIPMENT TO BE INSTALLED ***************~*}*************~*~t********* ~Vic~~2- : A -F-o~-~Q o`~ 0 U i'~ 1 ~ S ~U U~ ~`~ r~ i~Yt~ v ~c~ '~irow~ ~L~t~~. ~r~ s~S~v- Gve,~- ~e (cash-. (~Lr,-~, ~cvc>.~, ~~ ~'t~'~e Ur~, ~~5 1-,c~.d -~-~ :~ I~~c~ r ~o w~5~ ~..~~ ~. 3 ~~ `~tt..es ~ ~.~.tr ~ ~~, ~ ~r.~ cti r ~%i ~1 ~C..~1~:'.Vl ~ . (over) i Section II Septic System Inspections: A. All applications for septic system installation, alteration or repair, as required by the Town of Queensbury Sanitary Sewage Ordinance, shall be submitted to the Building Department at least 24 hours before start of construction and shall include a plot plan showing: 1.) the proposed location of the system 2.) location and distance to lot lines 3.) location and distance to structures 4.) location. and distance to any water supply 5.) size and dimensions of all tanks, distribution boxes, the fields and/or drywells B. No system shall be covered before inspection and approval by the building Inspector. Failure to comply with this requirement may result in the uncovering. of the system by the installer and a fine of up to $250.00. C. An approved copy of the plot plan shall be available on the construction site. Failure to produce said plot plan at time of inspection may result in an immediate work stoppage. D. Should unforeseen problems during construction prevent proper installation, alteration or repair of an approved system, a new proposal must be submitted to the Queensbury Building Department before further construction. I have read the regulations above and agaree to abide by these and all requirements of the Town of Queensbury Sanitary Sewage Disposal Ordinance. Signature of responsible person: c Date: ~ - Town of Queensbury Building and Code Department Bay at Haviland Road Queensbury, New York 12801 (518) 792-5832 SETTLED 1763 ... HOME OF NATURAL BEAUTY ... A GOOD.PLACE TO LIVE C " fl v Q4tIeensLuery 90n O DEPARTMENT S%JILDMr., an and Z d Road, R.[)- 1 Box 98 Bay and Ha ryew York i2601 Queensbrury. BUILDING INSPECTOR. ' S REPORI NAME fir+ LOCAT I ON h6j e p Permit NCs • �' 71� f I)2lt * � * � PR0�1ES] - YES NO Footing;IPi er Forms �•oundat.ior► Waterproofing Backf ill Framing Roof ing Sy.ding IN Masonry Veneer Rough Plu i ambnc3 Relief Valves Ext . porches Finished Floors interior Trim stairs & gailings� Cellar Drain Tile concrete Floorsf_ Plbg - Fj%tures Gar _ Fireproofing Door closers Smoke Detectors Chimney INSULAT1.C)" Foundation Floors walls Ceiling TRICAL INS"CTIOt3� �—� ~ - F IN AI, EI.L"C xyEwP&x A'pPROv �T,al Building Z3ext scheduled inspection Ccall whe ready? Remark. - YJ ss L C guildi 9 Inspector 6/gy md-vl THE NEW 'YORK BOARD OF FIRE UNDERWRITERS BUREAU OF ELECTRICITY A o Y . 41 STATE STREET, ALBANY, NEW YORK 12207 p{,� Deue August 12 , 198 '7 Appliration ,Vo. on ,file 00831x /r87 A bV � 318 THIS CERTIFIES THAT only the electrical equw' ment as described below and Introduced by the applicant named on the abooe application number in the premises of L . Thomas Warner , Rir _ 9 , CQueensbury , New York in the foilowing location, ❑ Basement 51 Iat Ff. 131 $nd FT. Out] .side" Section 3 5 Black Lot 4 was examined on !/ g f/ and fa"nd to be in compliance wich the req"irements of this Board. >ti FIXTURE AICl55 SWITCHES FIXTUIM RANG S COOKING DECKS OVENS DISH WASHERS EXHAUST FANS OUTLETSMCRIFT INCAMMWA HI rLMMESCENT I Y MO. I K- W- AMT. K. W. AMT. K-W. AMT, K. W. AMT. N. P. S 27 58 32 21 6 5 P'R DRYERS FURNACE MOTORS FUTURE AETLLANCE FEEDERS s►eck" RECI VT TIME CLOCKS EELI UNIT "CATERS MULTI-OUTLET DIMMERS s AMT. K. W. GH X. P. GAS N. P. AMT_ Na. A. W. G. AMT. AMP. AMT. AMPS. TRANS. AMT. N. P. NQOF T AMT. WATTS ryer 10 s 1 HWT # 10 5 20 SERVICE DISOONNECT No. OF S E R v I CMETER E AMT. AMP. TY►E jr 1 .e'• 3w 1 .!' SW 9 JF ]w S.I aw �'�• Ptk bCONU. OF CC Cd. , '� HI.{#6 •M• ND- Or NEU7tALY Of }, U RAL 1 F200 cb OTHER A►PARATUs: ... � � S - Smoke Detectors .ti a 4 ,r1 L . Thomas Warner /f Rt . 9 Lake George Road BRANCH MANAGER Queensbury , New York 12845 Per This certificate mutt not be altered in any manner. return to the office of the Board if incorrect. Inspectors may be identified by their credentials. COPY FOR BUILDING DEPARTMENT. THIS COPY OF CERTIFICATE MUST NOT BE ALTERED IN ANY MANNER. � BUILDING and ZofIIN{G DEPARTMENT Bay and Fiaviland Road, oad R.Dorj( 12B4i 96 oueensburY. EPORT BUILDING INSPECYC]R ' S,�/��.��'! NAME 9rJGi1 LOCATION ys iq r / Permit. NO • Date 3 '�---�- * * * * * * w * * I, * " * * * �* s APPROVED - YES NO Footing/Pier Forms Foundation waterproofing Bad cf i l l Framing Roof ing Siding Masonry Veneer_ ��-�- Jiough Plumbing Relief Valves Ext . Porches Finished Floors Interior Trim Stairs & Railings cellar Drain 'Tile Concrete Floors Plbg • F i.xtul'es Oar . Fireproofing Door Closers Smoke Detectors Chimney rj 1XZN SU LAT I ON : 1° VVVVVM ��`�`Foundation Floors Walls ceiling TRICpIL IN ^~� FINAL ELEC DRIVEWAY ppPROVSurvey Final Building Next scheduled insp ection (call when ready) �j Remarks- /< suilding Inspector 6/85 and-vl flow" of Queerajl"ry BUILDING and ZONING DEPARTMENT Bay and Haviland Road, R-D, 1 Box 98 OueenSbury, New York 12801 SEPTIC DISPOSAL SYSTEM INSPECTION Q NAME 11�d1 �11 ^ LOCATION 13ATE /.R-PERMIT SOIL TYPE - Sand am Clay Percolation Test ed? YES - NO Percolation rate - Min/Inch _ TYPE of SYSTEM: Al,sorption field , total length Length of each trench Depth of trenches Size of gravely --— SEEPAGE PITS{Number of) _- —�- - Size- ft, X _ ft , Gravel s3.ze Size Type PIPING . Bldgw to tank Tank to dist. box Dist , box to field n Partial Openings sealed? ES LOCATION/SEPARATIONS : ft. Foundation to tank ft , Foundation to absorption Absorption to lot line ft.ft , Separation of pits LOCATION OF SYSTEM ON PROPERTY (circle one) Front - Rear - Left side - Right side - CCKMENTS we �.��� �"' Opp SYSTEM USE APPROVED ; NO !Building Inspector 01/86 and vl CC77 {{ --.14111111w r _Jown o� �ueens6urr� l BUILDING and ZONING DEPARTMENT Say and Havifand Road, R. D. 1 Sox 98 Queensbury, New York 12801 BUILDING INSPECTOR ` S REPORT NAME e � ), a- J Y1 T. Y)! © f= LOCATION Date Permit No . 138 ✓ = APPROVED - YES NO Footing/Pier Forms Foundation waterproofing Backfill )(F raami ng S,46e Roofing Siding Masonry Veneer y, Rough Plumbing Relief Valves Ext . Porches Finished Floors Interior Trim stairs & Railings Cellar Drain Tile Concrete Floors Plbg . Fixtures Gar . Fireproofing Door Closers Smoke Detectors Chimney INSUI.ATION : Foundation Flooars Walls Ceiling FINAL ELECTRICAL INSPECTION- w„ DRIVEWAY APPROVAL Final Building Survey Aiext scheduled inspection (call when ready ) Remarks- Building Inspector 6/86 and-vl _ laurel nl Queerr .s (rUP BUILDING and ZONING DEPARTMENT Bay ,and Haviland Road, R. D. i Box 98 Oueensbury, New York 12801 BUILDING INSPECTOR ' S REPORT LOCATION errv� �ry . yr� Date /; Permit No . ✓ = APPROVED - YES NO FDoting/Pier Forms oundation Waterproofing Backfill Framing Roofing Siding Masonry Veneer Rough Plumbing Relief valves Ext . Porches Finished Floors Interior Trim Stairs & Railings Cellar Drain Tile Concrete Floors Plbg . Fixtures _.. Gar . Fireproofing Door Closers Smoke Detectors m Chiney INSULATION Foundation Floors walls Ceiling FINAL ELECTRICAL INSPECTION DRIVEWAY APPROVAL Final Building Survey Next scheduled inspection (call when ready Remarks-- Building Inspector 6/86 and-vl .- .Ieswn v� �ueena6+urt�t BUILDING and ZONING DEPARTMENT Bay and Haviland Road, R.D. 1 Box 98 Queensbury, ,New York 12801 BUILDING INSPECTOR ' S REPORT NAME ,�,',r r /"fp LOCATION + Date _f permit No }erFooting/Pier Forms APPROVED - YES NO Foundation Waterproofing Backfill Framing Roofing Siding masonry Veneer Rough. Plurabing Relief Valves Ext . Porches Finished Floors Interior Trim Stairs & Railings Cellar Drain Tile Concrete Floors Plbg . Fixtures Gar . Fireproofing Door Closers Smoke Detectors Chimney INSULATION : Foundation Floors Walls Ceiling FINAL ELECTRICAL INSPECTION DRIVEWAY APPROVAL Final Building Survey Nex[ scheduled inspection (call when ready) Remarks- 6/86 and-vl Building Inspector BUILDING DEPT_ COPY OF APPLICATION FORM ag-EL NEW YORK BOARD OF FIRE uNDERWRITERS. FILE THIS COPY WITH $"ILDING DEPT. WHEN ,REQUIRED. GITY OR DATE VILLAGE ..- STREET ANDNO- on' ROAD AND +� TOWNSHIP i C It - 1:: < i,r ! BETINEEF1 YYfiAr NO. ('! COUNTY J". ..J\ Il Y {"./'�/ CROSS STREETS is I '. PREMIS ' :� :'. POLE Nd. /t/4 NAME x l �€' h t.I v r 1 x / a _. ��. 1- t_ f SECTION OWNER's NAME V gkj r it BUILDING 8L K a OT AN D ADDRESS OCCUPANCY SUPPLIEDBy p �a 1 / TEL. # SUILDING r '.J �� I, I. V� _ Is .. FROM THEIR NEW L�7 OLD ❑ 'WORK ~� � `"� � OFFICE LIST BELOW ALL EQUIPMFi ICFI YOU INNEW i 1'AL LEODNAL �] DEFECT$ IS W REMOVED Q Loco- NUMBER OF OUTLETS Mo. of Fiatut A tion Lamp Raeepta las MOTORS Clowling Bids A "EATERS CIRCWTS Wall R ss Sritah Pendant Bracket NCkst- o. T N.1! OFOIYLY use Skbvpe Each No. EWadi No. ADS 11VS,PECTION blare Sava• matat Tat Ff. .Tnd Fl. 3rd Fl. REMARKS: LIST OTHER ELECTRICAL DEVICES NOT SET FORTH ABOVE; O6 NOT USE THIS SPACE, This application is int"dao No cover the You are "thistiaed to maka the i abova'lisfad Wttisaalent to 1" i nsPacNon anal +d1M+s1 the faa So cover fha Additnspatroadional lout iF at lima of insif+action there a found SIZE OF equiprrMnf, as Prdyided 1+Y thr applicant, addirkpnrl equipment not NyRas elated. MAINS �.- �, F EEDdERS ELECTRIC SIGN CHARACTER OF WORK LAMPS TOTAL EXPOS:EO STARTED WATTS N WORK TO BE r COCEALED GAS ruse slop, TRANSFORMERS OF SERVICE OVER COMPLETED (NUMBER] VA ENTERS OVERHEAD 'UNDERGROUND SIZE OF SIGN fCAPACITYI IL ITI - MAK�R'INSPECTION REOUESTEO OAg" ON OR AS NEAR AS P[i.SSfBiLE AVOID DELAY BY GfVIMill FULL AN8 ACCURATE INFORMATION- ALL SPACES' MUST RE FILLED !N On APPLICATION MAY BE RETURNED, NE91t OLD NAME F INE AMID ADDR SS ., DATE OF NAME OF ,r --/ I '> APPLICATI APPLICANT ._ L /J S� ( � O + [ ' SIGNATURE `— -----. STREET ADDRESS / / OF APPLICANT, —t— f{f l LSi 3 {SL✓l CITY OR �r POST OFFICE "—'^�E-�`i� TELEPHONE iOf'___ ' ''~ "�, ZIP 46 EL (wee.. vea) A SEPARATE APPLICATION cODE i„? ' cf^ .. — LICENSE No ------ MUST BE FILED FOR EACH SEPARATE BUILDING, ~ (~, ~' ~ 3 ~ ~ ~ ~ d r .~ f~ ~ l'~ Q _ ~ ~ 4 ~ J a m t ~ ~ ~ ~. ~ a e 2 ~ ~ ~ d a a T 4 g J ? ~ ~ ~ ~ ,~ ,~ ~ a N ~ Q T ,M 3 O 1 u~ . ~ r ~ 3 ~ . ~ ~ 3 ~r ~ a p a ~ s , ;~ ~ f 4~1 ~ ~ ~ ~ ~ ~ f ~ '' ~ T ' ~' N ~ { d y ~ ¢ w %G 9y `; ~ 2 ~ ~ Z 0 ~ 0 ~ ~ a a J '. o \ ._ ~~ d ~~ 'oa. ~O~ J ~~ S, c ~ ~? ,~ _ •~ r.\ ,c~~ ~~ / ~ ~ ~S i,' / L ~ 0 /v ~ r ~'- ~ %~, ~ ~o- ~~ r 7i ~ _/ / i ~\ ~ ~ ,,~ \ ~• ~ o J ~,r a f ~ ~ ~il ~ ~ cJ ` ~ z W LL 4 ^~ r :~/ ~\f ~_ 7 ~3 ,, 1~ ~ ~/ ~`i ~ ~ ~ ~ ..~ • ~;. ~ ~ °' i : ,o ~ ~ ~' 4` ~ } ~ ~ vnj . N h ~ ~~~ d, ~ ~~ ~ • po. ~~ G~V ~S`~ ~ l . ' ~..J 0~ 2~ 9 ~ . \~~ . ~;.~' ~. ^~ M ,;• c'. ~/ ~~ cC- 4 /+ .~- w. 4 ~ 7 ~. s ,. ~ . u #"~.~' . 33 ti ,•v - 4 r~~ 1 ~' #~ y x ~' ~ ~: 1 ~; ~ ~~ +~ ~.__..~..~..__ f ~ ~~- orv Czo~c SE~-rG J ~'~~ C..~e ~°. a c~ E'.Gr<' ~- a vG ~~~~ 7 ~1 ,2 ~ 3 I° bar ~ t -+s ~' c~ s y s`~rN~ ~ xl raa,~r ~ a r~s~ f ~ ~, u ~~ nr ~.~ u ~~ it lt. N O U C ce' '~`' ~ b u.~ .-- ~~f~~~ ~ .,sr' ~~ ~,.._~ ~s ~~gbx .~ `w~s~ 8 Erg 1~ ffs ~ ~~t Pa ~~~. f ~ ;~. ~~ o~ ~~, ~'~'i- 9 --~ ova rr~ t ~ ~r . ~,~° c r~~~a ~1 a