1987-444 i
low
IN
1
DERTIFI AT,E OF +C.�C+�UP'AN+�Y'
TOWN OF QUEENSSURY
f WARREN COUNTY, NEW YORK
Date December 28 , 19 87
4141
This is to certify that work re4uested to be done as shown by Permit No, y 87-444
� has been completed. rl,
This structure may be occupied as a One amI3wl ink
Location Rt e . 149
f {�
Owner I3arue Ma3ii�� `
1
I
By Order Town Board
I
TOWN OF QUEENSBURY y
I
f Building & Zoning Inspector
I
I
f
BUILDING PERMIT � T
TOWN OF CCU EENSBURY No. 87-444
WARREN COUNTY, NEW YORK a
PERMISSION is hereby granted to Harvey T . Mailie
t.}
V
OWNER of property located at Rte . 149 Street, Road or Ave. w
•J
in the Town of Queensbury, To Construct or plans a Ong—Family Dwelling w
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_
t. OWNER'S Address is
West Glens Falls ,
Glens Falls , N . Y . 12801 m
n
C
rn
2. CONTRACTOR or BUILDER'S Name
H
Town & Country Construction Co .
N•
3. CONTRACTOR or BUILDER'S Address !—*
N•
m
Fort Edward , N . Y .
4. ARCHITECT'S 'Name
5. ARCHITECT'S Address
rr
iD
6. TYPE of Construction — (Please indicate by X)
{ Wood Frame ( ) Masonry ( ) Steel I k
7. PLANS and Specifications
No_ 261 X 72 ' One family dwelling Including 2 car attached garage and
septic system as per plot plan , specifications and application . Variance
B. Proposed Use No . 1054
One—Family dwelling
I
$5 . 00 C /O
$ 101 . QO PERMIT FEE PAID — THIS PERMIT EXPIRES February 1 , 19 88
[If a longer period is required an application for an extension must be made to the Building and Zoning inspector of the
town of Queensbury before the expiration dete.i
fD
Dated at the Town of Queensbury this 14th Day of July 19 87
G-
. ��. '
SIGNED BY � for the Town of Queensbury
Building and Zoning Inspector
TO BE COMPLETED BY BLDG . DEPT .,
Application No .
fiL(I/Z fi ttQ@rt3i?ttM1 Permit Issued 19
BUILDING and ZONING DEPARTMENT Permit Expires 19 = (.)vvN (D+ Aadk- 9 GC' Jv •.
Bay and Haviland Road, R.D. 1 Box 9$ Zoning Designation ( P
Queensbury, New York 12801 Variance No . Ili d.5
�� '�� Site Plan Review No . JUL +IJOI
,�}g
�✓'Y""J r •
" .Approve y w.
APPLICATSON FOR I BUILDING a CODE DEPT.
tof
FU I ED I NG AND ZONING PERMIT -
+� :
A PERMIT MUST BE OBTAINED BEFORE BEGINNING CONSTRUCTIONe, ANSWER ALL OF THE FOLLOWING .
The undersigned hereby applies for a Building Permit to do the following work which will
he 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 : / r� rp ,,r V �/� 7rj,► i� , I �7
P . D. Address L� Li S f (�r' ,/�-� f L � Tel .
Property Location : /9j 9 Tax Map Noe
Street number or building lot number
Subdivision name ( if applicable)
THE PERSON RESPONSIBLE FOR SUPERVISION OF WORK AS REGARDS BUILDING CODES IS :
Lryt� G.T
Name P . O . Address Tel . No .
Name of builder * ¢ w,v Paz , T a y Address Aa 1_. 4 ....144xj Tel . 9- Ily(PA 6
Name of plumber. Address _ 6Q A:I TeI .
L;"c� +9.Qoe4
Address /� A% s,rry� Tel . } '�E2 kEA44 Name of mason 7G w-..-- � G v ��r,�.�( �,
DNATURE OF PROPOSED WORK : * ZONING INFORMATION :
/
1,/ 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 .
Size of property � cs .i ft X jqAr ! _ ft .
* Existing buildings) Size ft X £t .
*
PROPOSED BUILDING AND USE : * Existing building ( s ) Use
Size of new structure ft X / off. ft
Foundation-pier/slab/crawl/partial/full * Proposed building , distance .from property line
(circle one )
Now of stories (habitable space ) _ * Front yard Y Y £t Rear yard f a ft
Height ( grade to ridge ) ft . * Side yards '� J ,5 _ ft and 12] ].s ft
If residential , no . of families * if on corner , setback from side street ft
Now of rooms ( excluding baths) s OCCUPANCY INFORMATION
No , of bedrooms
Now of bathrooms PRIZ4ARY BUILDING -
Primary heating system 4_4 &, r-WKI r, * V One family dwelling
* Two family dwelling
Type of fuel
No . of fireplaces to be installed ,itL * Multiple dwelling / Number of units
Will a wood stove be installed? 'y * Permanent occupancy
'Transient occupancy
Central Air conditioning? �,g,�d * _Business
BUILDING STYLE, PRIMARY STRUCTURE * industrial
Ranc Contemporary Log cabin * Other ' 7
Raised ranch Mansion Duplex * If addition , what wi11 use be .
Split level Old style Bungalow
Cape Cod Cottage Other 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
INFORMATION ON BUILDING SPECIFICATIONS , ON REVERSE SIDE OF THIS SHEET , TO BE COMPLETED !
Form SPA 4/86 and-vl
BUILDING PERMIT APPLICATION CONTINUED -
BUILDING SPECIFICATIONS :
Type of construction , wood frame , fire safe , etc . Li.46
Will any second-hand or ungraded lumber be used? If so , for what? _oaZ13
Foundation wall material f�'1r Ci y mr� ,,.wj 1% rao4L.-Tt- Thickness '
Depth of foundation below rade (to bottom of footing ) _ _ r
Will there be a cellar? �et 5 Heated or unheated? &4 ✓ Floor sq. footage LjL!2j�, _ sq ft
Will there be a basement? V4x-s Will any portion be used as living space?_ I V
( I£ so , what portion? ,,&,,LV sq. ft . - - Type of use?
Type of roof - shed/flat/shed/otherFyt, 4 i Material of roof
'Size , wood studs .�"XM�_" spacing-"o . c . length �ft.
Joists { floor beams} lst . floor "X �" spacing_,,_"o . c . span -ft .
Joists ( floor beams) 2nd . floor "X of 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) spac3n1g��"o . c0 span �ft .
Exterior wall finish �, j-� ,L_ q" ; Lr p Of what material?
Interior wall finish � 3/ �,� ,g4 �
If a garage is to be attached , describe mat ials to be used fo FIRE SEPARATION :
r : �- co a b 7� y cc'-'g A-L .
is there to be an opening between garage an'A dwelling? 4.r.5 If so will a Fire-rated
door , enclosure , and self-closing device be provided? {,rIr-,r _
Will a flue-lined chimney be installed? �, . n Height above' roof y' u ft . -
Depth of chimney foundation below grade ,n,rd f t .
Depth of fireplace hearth_ ,elf: ft . in .
Water supply - Municipal or private well I�it� Cr"LL.
SEPTIC SYSTEM _ Distance from ANY private well ( including adjoining properties y_ ft .
(A separate application is necessary for any repair or new installation of septic system)
Town of Qu,eensbury C I I
County of Warren A F r D A V T STATE OF NEW YORK
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 agentrarcbxrect , contractor -
day of 19_ � r -�
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 :
10 Gross floor area� rs-r>
2 . Type of heat ` L
3 . Is the building mechanically cooled ? ,�/ ()
4 . Percentage of area of windows and doors
A , Over 164 Only
1 . Uvalue of gross area of walks , roof/ceiling and floors
exposed to ambient conditions
2 . Floor over heated spaces YES NO
a . Are foundation walls insulated ? YES NO
� 10 If YES , what is the R value ?
3 , Slab on grade YES NO
a . If YES , what is the R value of insulation around
perimeter of floor ?
4 , Is basement heated ? YES NO
a . R value of insulation
5 , Type of insulation
B . Under 16 % Only
10 R value of roof and floors exposed to ambient conditions
20 R value of exterior walls - ,S
3 . R value of glazed area. 2 - LE
4 . R value of doors . T4r
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 '—
B , R value of heated basement/cellar walls { above grade }
9 . R value of heated basement/cellar walls {below grade ) �
la . Type of insulation :r 4-di5r�r9dr
C . Controls
10 Thermostat maximum jheat setting fT ° U
D , 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
E . Piping Insulation
1 . Size of hot water or cooling carrying agent pipe 3
2 . R value of pipe insulation
F . Service Water Heating
1 . Performance efficiency. _ 010
2 , Temperature control setting maximume
f G . For swimming Pool only
1 . maximum heating ti " d /jr-Lr.4�"
l.
1ephOn@ Woo / ! � iC� E� �* ¢� t'� •, � +rJD wt.✓ .�f!?tn..J ]� e'�.tr �rw�' �Jy' l
( applicant ' s signature ) "
,An oueft df Qeew6avop
APPLICATION FOR SEPTIC DISPOSAL PERMIT
DATE // l / Jt�
LOCATION OF PROPERTY FOR INSTALLATION 4 /
Owner's Name : A09 02 tic L�4r ,lr�.� ,�; _ Telephone:
Address:
Installer's Name: 'fo u .ti^ 4- Ca c.n C.6n- S ,~ Telephone: tf
Number of bedrooms (residential only)
Total daily flow (compute @ 150 gal per bedroom) i G ,/Jg� L..-
Topography. circle one: Flat Roiling Steep Slope -;t a% of slope
Soil Naturee. circle one: Sand Loam Clay Other / Depth: feet
Cu-ound Water: At what depth? /✓ Q feet
Bedrock or Impervious Material: At what depth? ,��, d feet
Percolation test. circle one: not required required J rate min. inch.
Domestic water supply: circle one: Municipal Well Other
IF domestic water supply is a Well:
Separation: Watersupply from Septic absorption / ¢ p feet
PROPOSED SYSTEM: Septic Tank 0 0 O gal. (minimum size: 1 ,000 gal.)
TILE FIELD: Each Trench 610 feet / Total system length 9-0 U feet
SEEPAGE PIT(S) : Number of / Size each feet by feet
Size of stone to be used # O J Depth or Thickness '�- feet
I M P O R T A N T
...Please...LJST NEW EQUIPMENT TO BE INSTALLS
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
(over)
Section lI 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, tile 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 agree to abide by these and all requirements
of the Town of Queensbury Sanitary Sewage Disposal C*%jirLa ce.
Signature of responsible person: C
Date: _ T Z
Town of Queensbury
Building and Code Department
Bay at Haviland Road
Queensbury, New York 128() 1
(518) 792--5832
SETTLED 1763 . . . HOME OF NATURAL BEAUTY . . A GOOD. PLACE TO LIVE
._lawn o/ Quee" J "ry
BUILDING and ZONING DEPARTMENT
Say and Haviland Road. R- D. 1 Box 98
Queensbury. New York 12801
BUILDING INSPECTOR ' S REPORT
NAME
LOCATION
Datl 0 / Permit No . � /�
APPROVED - YES NO
Footing/Pier Forms
Foundation
Waterproofing
Backfill
Framming
Roofing
Siding
Masonry V neer _
Rough P1 ing --
Relief Val es
Ext . Porche
Finished Flo rs
Interior Trim
XStairs & Raili gs '
Cellar Drain Tim
Concrete Floors
plbg _ Fixtures
Gar . Fireproofin
Door Closers
Smoke Detectors
Chimney
INSULATION :
Foundation
Floors
Walls
Ceiling
FINAL ELECTRI AT. INSPECTION
DRIVEWAY APPR VAL we
Final Building Survey _
Next scheduled inspection (call when ready )
Remarks
Build ng nspector
6/86 and-vl
f �ocvn o� i,� ppn ,y � ure�
BUILDING and ZONING OEPARTIMENT
' Bay and Haviland Road. R.D . I Box 98
�} C)ueensbury. New York 128D1
g DING I NSpECTOR f S REPORT
1 ,
NAME
LOCATION K
Date Permit NO * / —F-
* * * *
APPROVED - YES NO
Footing/Pier Forms
Foundation
waterpro ing
'Sack£ ilI
Framing
Roofing
Siding
Masonry Vene
Rough Plum iLn
Relief 'Valves
Ext . Porches
Finished Floors
Interior Trim
stairs & Railings
Cellar Drain Tile
Concrete Floors
p1b. . Fixtures
Gar . Fireproofi
Door Closers
Smoke Detector
Chimney
INSULATION
Foundation
Floors
walls_
eiIIng
INAL EL TRICAL INSPECTION
i?RIVEWAY APPROVAL urvey
Final Building
ectiorn (,call when ready )
Next scheduled inap
IeC4 y�
Remarks— rr .
pq,Pd
crwLmIlAi
Bung Ins actor
6/86 and-vl
4208090 THE NEW YORK BOARD OF FIRE UNDERWRITERS �
BUREAU OF ELECTRICITY
F— A . Y . 41 STATE STREET. ALBANY, NEW YORK 12207
Dote December 8 , 1987 Applicat ion No. onfile 026443 / 87 A 7U1� 519 �.
THIS CERTIFIES THAT 1
only the electrical equipment as described below and intra4zeced by the applicant named an the above epplication number in the preaais" of
Harvey T . Maille , Farm to Market Road , Queensbury , New York �
in the folloteing location; � Pasem.ent [71 lst Ft. ❑ 2nd Fi. OU t S 1 d e Section Black Lot 1 -
"Wo examined an 1 1 / 1 0 / 8 7 and found to be in compliance with the requ.ire+raertta of this Board.
FIXTURE F7Ati1lS FIXTURES RANGES COOKING DECKS OVENS DISH WASHERS EXHAUST IFANS
OUI.TTS SwISWITCHESINCANPwsrANT PLUDRESCENT I AMT. K. W. MAT- K. W- AMT- K.W, AMT- K_ W_ AMT. i H. P. 1
16 43 21 3 FIt VE
DRYERS FURNACE MOTORS FUTURE APPLIAtiCE FEEDERS SPECIAL RRC'IPT TIME CLACKS BEtI UNIT HEATERS NVINTtOUTt1T DIMMERS
a1L H. K GAS H. P. AMT_ NO. A. W. G. AMT- AMP. AMT. AMPS. TRANS. AMT. H. ►. OF� AMT. WAT't5
rE
1. HWT ff 1
SERVICE DISCONNECT PI D, OI S c E R p V 1 C p E
AMT. AM►, TTPE 1,0 2W 1 X sw S Ar 9W 9 X 4W �' �9 jc. CONC C!F CC 4tMJd. No. DP "14AG - OR it% ML QP MEUIW.S
1 lop cb 1 1 4 / Gl 2 / 0
OTHER APPARATUS:
Electric Room He'alters -- 3 - 2 _ O KW
4 - l . S KW
2 - 1 _ 0 KW
2 - . 7 s KW .
si
1 - Smoke Detector
Town & Country Coast . r 101
RR # 1 Box 1642 - Rt . 196 -�
Fort Edward , New Yor [:. 12828 BRANCH MANAGER
Per f
This certificate must not be altered in any manner; return to the office of the Board if incorrect. Inspectors may be identified by their tredentich,
COPY FOR BUILDING DEPARTMENT. THIS COPY OF CERTIFICATE MUST NOT BE ALTERED IN ANY MANNER.
flow" 0/ Q"een3lury
BUILDING and ZONING DEPARTMENT
Bay and Haviland Road. R.D. i Sox 98
Queensbury. New York 12801
BUILDING INSPECTOR ' S REPORT
NAME
LOCATIONp ,+��./re+
/' /�• Permit Nc� .9./7s�'"<
L7ate_` / j
* * * * I* : " * * *N^,* * *
APPROVED - YES* NO
Footing/pier Forms
Foundation
Waterproofing
Baclkf ill
Xyraming
Noo f ing
)CSiding
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
Chimney
IN suLAT1ON
Foundation
Floors
Walls
Ceiling
FINAL ELECT CAL INSPECTION�_� �-
DRIVEWAY APPROVAf
i
Final Building, Survey
l en ready )
Next scheduled inspection (cal wh
Remarks—
Building Inspector
6/Sf� and-vl
�Jot.vn of QueensI ur y
UI DING and ZONING DEPARTMENT
and Naviland Road, R. L7, 1 Box 9B
} pueensbury, New York 12801
[7V 1 4
SEPTIC DISPOSAL SYSTEM INSPECTION
(�[
NAME L C
LOCATION
DATE 3ft.0/ PERMIT NO * �t' r
SOIL TYPE - Sand Loam - Clay - a
fired? S
g
Fercolation Test Reu '
Percolation rate - Min/Inc1.
�i
TYPE of SYSTEM: en th
p bGorptio field . total
Length o h trench
Depth of tre hes .,c
Size of grave xg: o£.
SEEPAGE FITS4N £t_
Size- ft
Gravel Size size Type
PIPING = tr .- . 0 Bldg , to tank
Tank to d3 St . ielc3 �,r
Dist. box to Par _~-
openings se ed?
tial
LOCATION/S A,RATIONS = t_
Foundat.io to tank to
to absorptio
Foundati ft.
Absorpti n to lot line t.
Separat ' n of pits
VS Ito TX (circle one)
LpCATI i.ght side
Fran Left si e
CC"MENTS
SYSTEM USE APPROVED ES NO
B?iaing Inspector
01/86 and Vl
SEEMS
/I � JaW" Of Quee" 4"rrif
lSUIL'DING and ZONING DEPARTME
, Bay and Hawiland Road. R.D. , Sox 98
UU '(�l" Queensbury. New York 12801
BUILDING INSPECTOR ' S REPORT
NAME
LOCATION
.O C A T I O N pexrni7
'DatePermit, Noe `
* * * * * * * * * * * APPROVED - YES NO
Footing/Pier Forms
e.F'ounda tian
Waterproofing
v{3ack€ill
Framing
Roof ing
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
Chimney
INSULATION
roundation
Floors
Walls
Ceiling
FINAL ELECTRICAL IL3SPECTIQN��.
DRIVEWAY APPROVSurvey
Final Building
Next scheduled inspection (call when ready)
Remarks-
r
Building ctor
6/86 and-vl
own ofueens � etrt�
BUILD't,4G and ZONING DEPARTMENT
{J gay and Haviland Road, R.C1. 1 Sox 98
aueensbury. New York 12601
' BUILDING INSPECTOR ' S REPORT
NAME
LOCATION f Q'
1� dyca �
Datle7 Permit No
YES NO
s AppROVED
r oting/pier Forms
! Foundation
Waterproofing
Backfill
y Framing
Roofing
1 Siding
Masonry veneer
Rough plumbing
Relief Values
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 IN]SPECTI017
i3RIVEWAY RPPROV Building Survey
Final
Next scheduled inspection (call when ready)
Remarks- F�$ a `'� �� r �
Building Inspector
6/86 and-vl
Qu
i 1 , BUILDING and ZONING DEPARTMENT
�1
Say and Haviland Road, R_C1. i Box 98
r pueensbury. New York 12801
BUILDING INSPECTOR ' S REPORT
lip
LOCATION L %
Date- , Permit Nooppippir97� •
// #f APPROVED NO
t' Foot.ing/Pier Forms
Foundation
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 . Fireproofin
Door Closers
Smoke Detectors
Chimney
IN SU LATI ON
Foundation
Floors
Walls
Ceiling
FINAL ELECTRICAL INSPECTION
DRIVEWAY ApPRdVAt
Final Building, Survey
Next scheduled inspection (call when ready
Remarks-
V
Building Inspector
6/66 and-vl
BUILDING DEPT. COPY OF APPLICATION FORM 46-ELo NEW YORK BOARD OF FIRE UNDERWRITERS.
FILE THIS COPY WITH BUILDING DEPT. WHEN REQUIRED.
r ,r TLMP. s ♦ DATE .
CI an
VILLAGE L £ 1 i fr .. TOWNSHIP i / (,.. .y " i t t.. COUNTY
STREET AND NO, OR n -'- / t-`
ROAD AND POLE NO 3 I POLE NO.
BETWEEN WHAT TWO
PPpROM EMIIS SRLOCATEDT d" r -I6ETS Is { 1\ T t - / �• , ' �- SECTION r` BLOCK LOT
OCCUPANT'S BUILDING
NAME .✓ ,� ✓ L. J ,/'r�I,. .' . L- f L: OCCUPANCY -
OWNER'S NAME :- TEL.AND ADDRESS ./ �.:' -•7f : . / r' i.l ,i�
1.URREIGT
SUPPLIED ,�. f FROM THEIR OFFICE
BY J" a �,�"' ,mow'
BUILDING DEFECTS
Is NEW I=1 OLD IRK NEW ADDITIONAL 0 REMOVED
LIST BELOW ALL EQUIPMENT WHICH YOU INSTALLED
NUMBER OF OUTLETS No. of Futur4a &Lamp Receptacles MOTORS MEATS R$ BRANCH
CIRCUITS OFFICE USE
r ONLY
Loc
Lion SMa AttowlHP.
OlPiny WaY Remap'h 8wirosll Fr.Idellt Bracket No. Type Gash 1"'0• E No. A.W.G. INSPECTION
Out-
ekN
sell
Ilene
t
Bess•
Illtstt
lot Fl.
204 FI,
3rd Ft.
REMARKS: LIST OTHER ELECTRICAL DEVICES NOT SET FORTH ABOVE: DO NOT USE THIS SPACE.
This application is intended 10 Gower the abs+n-hsted squipn"nr to be innpsctsd but if at time of inspection dv~ is foand edtiiti011et equips t not above Ibxsd,
you are authorUod to make the impaction and adjust the fee to cower who additional equipment, as p'owkied by the appliesnt.
SIZE OF ELECTR IC SIGN TOTAL.
MAINS FEEDERS LAMPS WATTS
CHARACTER EXPOSED GAS TUBE SIGN
OF WORK CONCEALED TRANSFORMERS OF VA
WORK TO BE iNUMBERI K:APACITYI
STARTED COMPLETED SIZE OF SIGN
SERVICE OVERHEAD UNDERGROUND MAKER
ENTERS OF SIGN
f lNG
INSPECTION REQUESTED
ON OR AS NEAR ASEj
POSSIBLE NEW OLD
AVOID DELAY BY GIVING FULL AND ACCURATE INFORMATION. ALL SPACES DATE OF
MUST BE FILLED IN OR APPLICATION MAY BE RETURNED. APPLICATION
PRINT NAME
A4D ADDRESS
NAMEOF
APPLICANT _ / 1 / XOF APPLICANT./f
STREET ADDRESS - - t ✓l,T f - -- ! - TELEPHONE -
CITY OR r
f L �''" C L CODE '�'e"S" c.; I LICENSE NO,N APPLICABLE
POST OFFICE
AG E� (REV. IISa) A SEPARATE APPL tATtON.MUAT BE FILED FOR EACH SEPARATE 1UILDING
t
,�trsd { 4V
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