1985-430 179. 1 C
OWN
CERTIFICATE OF OCCUPANCY n
TOWN OF QU'EENSBURY
WARREN COUNTY, NEW YORK
Date octe }Y c r 27 19 '�
This is to certify that work requested to be done as shown by Permit No,
has been completed. �1(" lA Wkx ( :
This structure may be occupied as a
'I c -•,_r a r'r ' 1 V l+' u 1 c. r F7Ic'. L 3 - � nc?
Location l ' ay .i. 3. and )\-venue � -C,
Owner
By Order Town Board
'TOWN OF QUEENSBURY
Building & Zoning Inspector
E RE hT1�'E "1ti"wT w" PR11w T1NG. GLENS FwLl3 N v 12601 I910I191-9464
BUILDING PERMIT
TOWN OF QUEENSBURY No. 85 _430
WARREN COUNTY, NEW YORRK
PERMISSION is hereby granted to Eric and Pamela Nelson
OWNER of property located at Haviland Avenue Street, Road or Ave.
in the Town of Queensbury, To Construct or place a Two—Family Modular Dwelling
at the above location in accordance to application together with plot plans and other information hereto filed and
approved and in compliance with the Town of Queensbury Building and Zoning Ordinance.
rf
C)
1 . OWNERS Address is 1fl Kenworthy Avenue
Glens Falls , New York sy
b
tv
2. CONTRACTOR or Bill LDE RS Name �
Assembly Developers & Tectonics m
z
3. CONTRACTOR or BUILDERS Address
flI
20 Saratoga Avenue b
South Glens Falls , New York
4. ARCHITECT'S Name
mi
01
S. ARCHITECTS Address C
N.
W
Inj
B_ TYPE of Construction — (Please indicate by XI
C
( 20 wood Frame ( 3 Masonry { 3 Steel { D
G
9. PLANS and Specifications ■ fD
24 x60 ' Per Plot plan , specifications and
application submitted including sewage system ,
No.
B. Proposed Use THE ATTACHMENT OF THE TWO PARTS MUST BE APPROVED BY 0
A LICENSED PROFESSIONAL ENGINEER . p W
Two_FaMily ss✓ �
rJ r -
$ 5 . 00 C/O Paid
$ 105 • CC PERMIT FEE PAID — THIS PERMIT EXPIRES March l 191 $ 6 "
(if a longer period is required an application for an extension must be made to the Building and Zoning inspector of the N
town of ClusensbutY before the expiration date-)
IJ
(N
Dated at the Town of Queensbury this 1 h Day of _ Augu sf-_ 19_a as �
SIGNED BY for the Town of Queensbury
Building and Zoning I nspector
TOWN OF QUEENSBUR`r � SpaRe inside block tai hc4 fillvil ill bt
WARREN COUNTY* NEW YORK Building Inspec•t+irl
\ sei No.
Application for ksR4l.1111t [%_�17Rd I9
BUILDING AND ZONING PERMIT Y1 .1-e11ie 1 -zliires 1!i
\ :Iltu' I I! '%Vorl. i
.\ � slsrnti•el he
THREE ( 3 ) Copies of a PLOT PLAN. Drawn to scales Ixt e11;e l-1�
showing _10F--- 4&
the actual dimensions of the lot to be built
upont Te exact sixes, and location on the lot of the .
building to be erected or altered MUST BE SUB-
MITTED WITH THIS APPLICATION.
�r August 9 , 1985 TC►WN CIF 44Q, UEE�t�' SBU R y
A PERMIT MUST BE OBTAINED BEFORE BEGINNING WORK
ANSWER ALL OF THE FOLLOWING. � ' ' � ,! i"��'►
The undersigned hereby applies for a permit to do +he following work A.N. � -p' 1 l •
which will be done in accordance with the description, plans and specifi- 7113 x 1213 � 415116
cations, and such special conditions as may be indicated on the permit. • � � �
The owner of this property Is:
Eric & Pamela Nelson 10 Kenworthy Ave . � , Glens , Fallst . NY I2801
. . . - IP D. ^1DaRESSI
eNA 'Ac{
The ,person responsible for supervision of the work insofar as the Building Code and the Zoning Ordinance apply i
.
INAMEY , - - - {P
Assemblyr e Dvelopers & . Tectonics . . Address a, Aver . t , So ., • Glens . Fall,s , . NY
Name of Builder
Name of Plumber . . . . . . . . . . . . . Address
Name of Masan . . .K'en Baldwin Address - . Hadlock Pond Rd. .,. [+7est Ft Ann , NY
Lot Number . . . . 3. • . . . . . Unit . . . . . . . Estimated value of proposed work $ - 48 , 0 00
Name of Villa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Name of Street . . . , , Haviland Ave . Side of street: north 0 , east G . south 0 west 0
. . . . . . . . . I . . . . - .
Thornberry, Drive Distance from this gross street 400 I t ,
Nearest Cross Street . . - . . . . . . .
Property is north ❑ . south 0 . east )St . west ❑ from Cross Street
If on Corner, which corner, northeast [31 northwest 0. southeast Lam . southwest
(Designate by marking with an "X" in the correct space.)
NATURE OF PROPOSED WORT{ OCCUPANCY
Main Building
E3 Addition to a building.
C-3X Construction of a new building. OneL]
Two-family dwelling-family dwelling91
0 Alteration to a building. Tw
-family apartment house 0
0 Demolition of a building. Store building 0
. . - . . , _ _ -car attached garage 0
Other:
Accessory Building
One-car detached garage Ci
O Other work_ Describe: C4,1 ` ^ ' Two-car detached garage El
Private chicken house
. . . . .
' ' ' � � � � Private storage building
. . . Other: . , . . , . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ZONING aPEeCIFICATIONS. Fill in for new building, or addition to existing building, or a change of occupancy.
W Indicate on the plot plan street names, the location and
ra size of the property, the location, size and setbacks of pro-
} i posed buildings, and the location of all existing buildings.
aNORTH Show proposed buildings) in dotted litre and existing
Haviland Ave . a--Xr% huilding(s) in solid line.
U " q Size of property . . . . , 240 _ . . . ft. x . . 2vQ0 . , . . . . . ft.
>1 Size and use of existing buildings, if any • • • '
u c W Size of proposed building 2A. . . . . . ft. x • . . €r0. . . . . ft,
0 Height (from grade to ridge) . . . . . . . . . . . . . . . . • . . . . ft.
E Front yard 30 to 60 . . . ft.
.
30 . . . . . . . and . . . 145 . . . . . . ft.
Side yards . . . . . . . . . . . . . .Rear yard . - - . . . . . . . . . . . . . . . . . . . . . . ft,
11D ,
SOUTH If on corner, setback from side street . . . . . . . . . . ft_
Note : All distances are not, as moissureed from street side
line to nearest part of building.
r� .fir {eb4 E R]
( 73 m
(cont'd,)
BUILDING SPECIFICATIONS,
Kind of construction: Wood frame, fire safe, etc.? . . . . . . J 1 1I Frame
Will any second-hand lumber be used? . . No. . . _ . . . . If so, for what? . . . . " . . " . . . . . . . . . . . . . . " . . . . . . .
Material of foundation walls . . . ,Concrete Block .
. 1`hickness
Depth of foundation walls below grade . . . . , . . . . 6 . f . . . . . . . . . . . . . . . . . . . . . . Continuous foundation? Yes
Will there be a cellar? . . Yes. . . If so, material of cellar floor Concrete
Sloped . .
Type of roof: Sloped or flat" , . . . . . _ „ , Material of roof . . ��4i, ,P?Yi"tood , 23,5 " Shingles
Size, wood studs - - - - - . . . . , 2. . . . . . , . . " x . , , . 4 . . . . . . . . , . ". spacing . . . . 1.6 . . . . . . . "o,c., length . . .7.s - , .• . . . . . ft"
Size. floor beams, 1st floor . . . 2. . . . . . . . " x . . . . $ . - . . . . . . . . ", spacing . . . . 1.6 . " . . . . . "o.c., span " . . 11 . . . . . . . . ft.
Size, floor beams, 2nd floor . . . . , . . . . _ - " x . . . . . . . . . . . . . . ", spacing . . . . . . . . . . . . . . "o"c., span . . . . . " . . . . . . . - ft"
Size, ceiling. beams . . . . . . . . . . 2. . . - " x . . . . 4 . , , . . - . . . ", spacing . . , " , . . . . "o.c., span . . . . . . . . . . . . . . ft,
Siie, roof rafters or beams . . . . 2. . , . . . . " x . . , . 4 . . . . . . . . . ", spacing . . . . . . . "o.c., span . " . . . . . . . . . . , . ft_
Exterior finish . . . . . . . . . Siding . . . . . . . . . . With what material?
- - - y'iAyX . . . . . . . . . . . . . . . . . . . .
Finish of interior walls . . , ", I}r y.wall. . p.4 jnt.ed . . . . . . , , . " . . . . . . . . . . . . . . . . . . .
If garage is to be attached, of what material is wall between garage and main building to be constructed?
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . " . . . . .
Is there to be an opening between garage and building? . . . . . . . . . . . . . . . . . " . . . . . . . .
Kind of heating system . . . . Electric. . . . . . . . . . . . . . . . . . . . . . Oil burner or coal? . . . . . . . . . . . . . . . . . . " . . . . . . , . . .
Will a flue-lined chimney be provided? . - No. . . - . - . . . . . Depth of chimney foundation below grade . . . , , " . . . . . . . . . .
Height of chimney above roof . . . . . . . . . . . . . . . . . . . . _ . . . . . . - . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Will there be a fireplace? . . . . . .No . . . . . . . . . . . . . . . . . Depth of fireplace hearth . . . . , . . . . . " , . . . . . . . " . . . . . . . . . . . .
Will a toilet be installed? . . . . . Yes. . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . .
Will a kitchen sink be installed and connected to water supply? . . . . . . . Ye,s . . . d , , . . . . . ,
Water supply (public water supply or pump) . . . . ?'ub I -
. . . . . . . . . . + . . . . . . . . . . . . . . . . . .
Distance of cesspool from any private well . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . feet
Will drainage system be provided with required traps, cleanouts, and vents? . . . . . Y''-A . . . . . . . . _ " . . . . . . . . . . . . . . . .
Town of Queenshury AF'F'IDAVIT
County of Warren
State of New York
1 swear that to cc A. j of my knowledge and belief the statements nonts' this application, easether with the plana and apeeiticatioos sctb-
mitted, area true and cu.. lets statement of afI proposed work w be a the described p and that a iotn of the BUILD-
ING CODE, THE ZONING ORDINANCE, and all other laws pertain' e osed work ii oarttpiied with, whether specified air not
and that much work is authorized by the owner.
Sworn to before me this Signature .. . . . . . .
¢e ER, O WN S AGENT, ,m,gCNITEC7. CONTRACTOR
day of. .. . . ._ . . . - . .. .. . . ... . . . ... . . ... 19. a.J.
NOTARY PUBLIC. WARREN COUNTY, N. Y.
SPECIAL CONDITIONS OF THE PERMIT:
By . _. .. . . __..... -. . _.. . . . .. . . . . . . . . . . .. . . . . . .. . . . . .... .. . . . ... .. . .... . . . _.
GECRGE KURDSr�0C€i .3Ft. . , Consulting En19!rleer , F . u . Box 660 Glens Pry' r1Y
PERCC I3 ATION TEST
1 . LsoCc' e� ho.! � S o--- 7P r?X . where. d-- S^.C?JCIl system is PRJ'Dl�oGco to L?C
i
2 . Eic} c� S to } 2 " .'amo-ttgnr hole 2411 to 3611 deep for 'file
frokk -51 to S ' for leach pits . ( 651 ' below isle fields & ) f2 ccr � fu =
dca !:k for L eac:z F i is . Dig holes the dcty before corzduc fir.
3 . Fill hr-AcA with wester at lec� t 1211 depth , let seep awry , { prey-00: 3. )
ay,pro>: . 24 hr>urs 1:;efore conducting final pert . tests .
4 . Clecx:k i,�o -ttoru cm' rxale of ctny loosa soil or other materi.cxl th6o � mcly ];.: ve
fallen In hole .
5 . Plc.c { rte_Usu'r -; nCI c eviCe in hole, do not t33 atiAr}? dur3nc3 test, ; v� <-. y �:'- Z-
t;..nct. ly ml .rk the 5 " C7Sl" 611 III.'"1. rk4 z-1 s , V: ATCnPPOOV Means On NAIL.
6 . C C.7." s_T I . IST ? ?ne g';' ?:C:t`' r .ln 'to } c• l {= y with a3F5 little Splass�'1n..ne a^ _ c^�f3 �,t'7 J.
the !Trai- ... .']. rk' i.T:ia Ls or Wz:'_Ter to ar0D
fi . Piet.^<xt e;:; o zni:3 .s ,_ ow 3 times , until the time requiixrc rs
2 tests give's G"-=,'{u1 l resin trj: dt`:I^ .,.?:I-Ay .
U rc' f or th.c -d- e . grk �,os i s for the systems .
m-4 n R.un # 4 26 min
n
=.n -r!} 30 min
Would u.ne ?l to 4_ _
TT.T-!i e�. -,-__ Rum No .
i go
._.._._. —_... - ._.__ _.. -- _ L _.._...� .. ... .�
4
�_ ____ � .___ ',� r.� ---.gym.. --•- G F%
c}i l Profile ----- -
d di.
TOWN OF OUFFNSBURY
BUILDING & ZONING DEPARTMENT �
k
SM7AGF DISPOSAL PERMIT APPLICATION J
ffi
1 . Owner ' s Name Eric Nelson {
Address 10 Kenworthy Ave . , Glens Falls , NY 12801 !`C
Telephone No . 793- 6171
2 . Property location Haviland Ave . Ext . , Glens Falls
34 Name of person or firm responsible for installing system
Dick Lee 'Telephone No . 793- 2363
Address Luzerne Road , Glens Falls
4 . Number of bedrooms ( residential buildings only) 4
54 Daily flow 600 Qallons/day
gallons
6 . Septic tank capacity
7 . Topography : flat , ' ollin steep
of slope
AM
8 . Nature of soil and depth
Q i
9 . If ground water , bedrock or impervious material is apparent at what
depth does it. begin? None f t .
10 . Percolation test : A xxxx is required
B. is not required
C req'u wed what is the rate='2 minutes/i ncfi
11 . Water supply : municipal , well , other Municipal
12 . Type of system proposed e drywel l , tile field , other, 'Tile Field = �,�4 #
Any contractor , corporation , individual , etc . engacied in the construction
of a sanitary sewage disposal system who ies from the approved nP covers the same before n ,
application
does not have an approved permit , or var
will be subject to a penalty c)f $ 250 as provided for in Section 6 . [110 of the
Queensbury Sanitary sewage ordinance .
Date August 9 , 1985 s g scant
tore o app
On separate sheet of paper submit a diagram of the proposed septic system
strucuredistance
with all dimensions , including distance � ro� anlncludetall ' dimensic+nsfofm
property line and domestic water supply , '
the system itself .
6?1 Ox
Form 3 - 8 2 „ ' �;�L„ - Ir5w1 C-c 4Ubw 510 % c `�
w 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 1440 PIUS Full Basement { %+%Aojouk>- ►w)
2 . Type of heat Electric
3 . is the building mechanically cooled ? No
4 . Percentage of area of windows and doors 12 . 3
A . Over 16 % Only
1 . U value of gross area of walls , roof / ceiling and floors
o
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 ?
3 . Slab on grade Acqxx NO
a . If YES , what is the R value of insulation around
perimeter of floor ?
4 , is basement heated ? S NO
a . R value of insulation
5 . Type of insulation
B , Under if % Only
1 . R value of roof and floors exposed to ambient conditions
2 . R value of exterior walls 19
3 . R value of glazed area 1 . 92
4 . R value of doors 10
5 . R value of floors over unheated spaces 19
B . 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 )
9 . R value of heated basement/ cellar walls ( below grade )
10 . Type of insulation Fiberglass
C . Controls
1 . Thermostat maximum heat setting 75
D . 'Duct Systems
1 . Is duct system installed in unheated spaces ? NO
a . If YES , R value of duct installation
b . R value of duct in other areas
E . Piping Insulation
1 . Size of hot water or coaling carrying agent pipe
2 . R value of pipe insulation
F . Service Water Heating
1 . Performance efficiency
2 . Temperature control setting maximum
G . For swimming Pool Only
1 . Maximum heating
Telephone No . 793-5771 rti
( appli nt ' s signature )
Cf Ay
TOWN OF QUEENSSURY
Building Department
IN
Maser.
Locutioe► !If
P NOW A - Y-3 a Weather
Remarks
xca0atson
Footin Forms
Footi.n & Piers
Foundation
Cement Coat
Water roofin
Backf-ill
Final Surve
Framxngr
Sheathin
Roof Fel t
RoofIn
Sidi n
Mason it Veneer
Rou h P1
Relief Valves
Wall Board
Ext . Porches
Finished Floor
Interior Trim
Stairs & Railin s
Cellar pro Tile
Concrete Floors
P1 . Fixtures
Gar . Fire roof.in
Door Closers � p
Chimne
water .Meter Inst .
5e tic A roval
Floors u
Fortnda tior2
Ynsulation walls -
Bu% 1d ' g InsPector
REMARKS
T,O VA OF C' EENSSU RY
RUSICUSIr Department
�upp . Rem .
natc dta � � • ems'
oe
Pmwa Now
Remarks
Excar�a Lion
Footin Forms
Footin & Piers
Foundation
Cement Coat
pp waterivroofin
Backfill
Final Surve
Framin
Sheathin
Roof Felt
Roofin I.
t t
Slain M�
lelasonr Veneer
Rou h PI
Relief valves `
Wall Board
Ex.t . Porches
Finished Floor
Interior Trim
gtairs & Railan IS
Cellar Dr . Tile
Concrete Floors
Pl Fixtures �t
Gar . Fire raafin
Dcx�r Cl users
Ch,{mne
Water Meter Inst .
Se tic A roval
Floors
FDLlndatibr) _�,-------�—
.rnsulation Walls
wilding .inspector`
REMARKS CV
Al
III OX
Id I
�' ST�'� N' �Gra 2QA'lG�rta'GS
r
Fief
our sew t 000R
TOWN OF QUEENSBURY
Building Department
Io�se�ors Repoet Date L
Name ttA
-
I,qrr flm
Pew Na $+ 3 Weather
Remarks
L.r
ExcatYa Lion
Footin ForMss
Footin & Piers
Foundation
Cement Coat
Water rooEln
Backfi.11
Final Survoe
Frami.n
Shea thin
hoof Felt
Rvofin a
S.I '
mason- veneer
Rou h P3
Relief Yalves � �
Wall Hoard
Ext , Porches
Ia.inished Floor
interior Trim 01 I.b
Stairs & Railin Is �P,
Cellar Dr . Tile
ConCrete Floors
pt fixtures
Gar . Fire raofin
Door Closers
Chimne
Water Meter lust .
Se t%c A -oval
Floors
Foundai Lion
Insulation Walls
Ceilin
Building Inspector
REMARKS
A rx SO srA�lS a r� i�#�Gt►IG�
.rk io�etfa"+r► ►s' Necas GAP
!'. RZ►G►NG $'! -ts�vt'r- �"�" c�+t-5 �'�.�. f3 s�S�i+'r't�'`
TOWN OF QUEENSBURY
Building- Department
lzopeetare RaRswrt Date
Name
Permit No. �L f eP% Wlm t er_
Excaoa ti on
Footin Forms
Footing6 Piers
Foundation
Cement Coat
' Water roofin
Sac&fill
Final Survey
Frami
Sxiea thin
Roof Pei It
Roofin
Siding
Masonru veneer
Roe: h P1
Relief valves
vitll Board
Ext . Porches
Finished Floor
interior Trim
Stairs S Railin Is
Cellar Pr . Tile
j Concrete Floors
P,g Fm Fixtures
Gar , Fire roofin
poor Closers
Chimne i
1 Water Meter Inst .
Se tic A roval t
Floors
Foundation
Insulation Walls
j Ceilin
Beeding Inspector
REMARKS
{
3
TOWN OF QUEENS►BURY
Building Department
f• l� Rleplerrt [late !!7 �
i Ham. T
Fesmnt No. � a Weather.
i Remarks
Exca tYa ti on
Footing Forms
Footing & Piers
Foundation
Cement Coat
Water roofin
Sacxfill
Final Survey
Framing
FEfSheathinof Fel t
Roof-in
Siding_
Masonry veneer
Rou h PI
Relief Valves
wall Board
Ent . Porches
Finished Floor
Tnterior Trim
8 Stairs & Railings
{
Cellar Dr _ Tile
Concrete Floors
PI Fixtures
i
Gar . Fire roofin
Door C,I asers
Chimne
Water Meter Xnst . or
Se tic A roval os? -
F200YrS
Foundation
Xnssulation Walls
ceiling
Building Inspector
REMARKS
t JyGs}} G a 44M i ioi j plc* o �
rrsra - zgsr -rrr + eAeH r=JS4.ar
Art z- LaS �F2 1 pvq- Ke too
{.,,.a!
i
TOWN OF QUEENSBURY
Building- Department
Pervak No. - wewllher
Remarxs
Exca0at on
Footing Forms
Footing & Piers
{ Foundation
Cement Coat
Water roofin
BaaJcfill
Final surve
Fran tin
sheathing
Root Felt
Roof-in
Siding
Masonry Veneer
Rough PI
Relief Valves
Wall Board
Ext . Porches
Finished Floor
Inter#or Trim
stairs & Railings
Cellar Dr . Tile
Concrete Floors
p2pza Fixtures
Gar . Fire roofin
Door closers
chimney
Water Meter Inst .
Se tic A roval
laors
Insulation Foundation
Walls
Ceiliri
2= � -
Building Inspector
REMARKS
TOWN OF QUEENSBU RY
Building Departmont
NAMMUM ---
j.AM:1kUM S4Yy
Pernsit No, B y' wc.tlaaar
3
Remarks
Oxcalow txon
Footing Forms ,
Footing & Piers
3 Foundation
Cement Coat
Water fin
BacJrfill '
. Final Surve
Frami
Sheatthin
{ Roof Felt
Roofin
Sidin
Masox.Lry Veneer
Rough Plbgo
Relief Valves
Wall Board IL
Sxt , Porches
Finished Floor
anterior Trim
Stairs & Railings
Cellar Dr . Tile
Concrete Floors
PI * Fixtures
Gar . FIxepxoofInqr
Door Closers
Chimne
Water Meter 2nst
Se tic A roval
Floors
Xnsulation Foundation
walls y
Cqaillnq
� 11 Ing Xns for
REMARKS
GEORGE KUROSAKA JR*v RE.
BUILDING SYSTEMS CONSULTANT
POIGT C *-Icc Box NO. 660
CiLE 40 FALLS, NEW YORK 1280t
(510) 702-1522
13 ARBUTUS DRIVE
OUEENSBURY, N, Y. 12801
PNONC 518 792 - IS22
BUILDING It LOPE OR /,4TWMip1
Town of Queensbury lice Factory Manufactured Home
Town Hall Installation Certification.
Queensbury , New York 12801
Attention . Mack Dean
Dear sir ,
This is to certify that I have observed and inspected the installation of a
"Factory Manufactured Home" * as defined by the New York State Uniform Fire
Prevention and Building Code , Chapter D - MANUFACTURED HOUSING . Article 2 -
FACTORY MANUFACTURED HOMES , as applicable to your local building regulations ;
there appeared to be no apparent structural damage to the units , due to or
attributable to the transportation or loading/unloading of the units , herein-
after described as follows :
Date of Installation : O''. '0 ,f-
Site T,ocation : +x��/e -��.�CV�
Community : Town of Queensbury
County : Warren
Manufacturer/Supplier : <7c;4h407rgFa+�t�G7rl�r��/,
Address :
Ines ign3.a Serial No . �,r
Plan ,approval No. A r C>cp S.s
Manufacturers Model/Component No . : .;;p ¢- .
Date of Manufacture :
Tnstaller/Supplier : .000r07f7r- � 0�".0'..
I have also examined the approved Plans & Specifications for the abovementioned
IlFactory Manufactured Homel' , and to the west of my knowledge and belief , this
"Home" has been installed in accordance with these approved Plans & Specifications ,
and all other applicable laws codes , ordinances , standards &/or vecaulations .
o) F NE
`F xU� �, Res tfull s ln3 t edr*
C's
GEORGE KUROSAKA TR . , POE *
cc : NYS PE Lic _ No . 35869
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