1987-703 � w
CERTIFICATE OF OCCUPANCY
TOWN OF QUEENSBURY
WARREN COUNTY, NEW YORK
Apvl1 :,5 98
} I?ate April 25 , 19 � t,
I . S � r �
This is to certify that work requested to be dome as shown by Permit No. _ a - ! E
has been completed. k01 u �rn f I)� `bwct I t �" cl
: I Two Fairaily Dwell tz � J
This structure may be ogcupi as a
�0 E I I
location 36 h11%abe1h Lane Qu�e�epn Victoria ` s Gram i�iodel .1
uli 15 1� p ILC . • 3L
Own, [
$y Order Town Board
TOWN OF QUEENSBURY
Building & 'Zoning Inspector
CREW T1VC "IM'�iTl4" rR�NTIN0. gLEN3 PnLIS. N Y ITa4� {����T43-36l4
BUILDING PERMIT
TOWN OF QUEENSBURY No. 87-703 �
WARREN COUNTY, NEW YORK o
PERMISSION is hereby granted to
Queen Victoria ' s Grant (Guyer Builders )
N
OWNER of property located at 36 Elizabeth Lane Street, Read or Ave. 1
in the Town of Queensbury, To Construct or place a of Two Family 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_
1 . OWNER'S Address is Guyer Builders Inc .
119 Dunning Street
Ballston Spa , N . Y . 12020
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2. CONTRACTOR or BUILDERS Name
Same
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3. CONTRACTOR or BUILDER'S Address o
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4. ARCHITECTS Name
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5_ ARCHITECT'S Address
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6. TYPE of Construction — (Please indicate by K) Imo••
to
03
( A Wood Frame ( I Masonry I I Steel I; }
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7. PLANS and Specifications MODEL J w
No- 32 ' x 48 ' per plot plan , specifications and application including f0
septic system, attached one car garage and driveway permit .
S. Proposed Use 1
Two Family Dwelling
0
$5400 CIO ~'
89 . Oa May 1 88
PERMIT FEE PAID — THIS PERMIT EXPIRES ' 79
$ 0
(if a longer period is required an application for an extension must be made to the Building and Zoning Inspector of the ray
town of Queensbury before the expiration date.)
W
87 ~
Gated at the Town of O.ueensbury this 20th��,,��,, �y.-77 _�_ Day of October 19 �
SIGNED BY cez for the Town of Queensbury
Building and Zoning I nspector
`"� 'J.'L] SYr C.'i7Mk'i•F.'1'l::L1 1S2 riLiRar L�-r.i, : ',
Application No .
,JOWn o ee,e�ria dbtsr� permit Issued 19 U ��, -` ; `, k{ `
BUILDING aid ZONING DEPARTMENT Permit Expires 19 + ^�C3
Say and Aaviland Road, R. D. 1 Box 98 zoning Designation ` 1�� . , 987
Oueensaury, Now York 12801 Variance No .
Site Pi Re law lam+
Appr ed, by • � � Sir
APPLICATION FOR
BUILDING AND ZONING PERMIT
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 : Guyer Builders Inc .
P. O. Address 119 Dunning Street Ballston Spa , New York 12020 Tel . ( 518 ) 899-9161
Property Location : 36 Elizabeth Lane Tax Map N0 .121 / 4 / 2
Street number or building lot number
Subdivision name ( if applicable) Queen Victoria ' s Grant
THE PERSON RESPONSIBLE FOR SUPERVISION OF WORK AS REGARDS BUILDING CODES IS :
Richard He Guyer III ( 518) 899-9161
Name P. Or Address Tel . No .
Name of builder Guyer Builders , Inc .Address 119 Dunning Street Tel . ( 518) 899--9161
Name of plumber yer ers , nCrAddress ng streetTel . ( 518 ) 599amr9161
Name of mason Guyer rs , nc .Addressjig Dunning Street Tel . -
NATURE OF PROPOSED WORK : * ZONING INFORMATION :
X 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
FOR DEMOLITION PERMIT , STATE SIZE AND * whether interior or corner lot . Show location
* of water supply and location and configuration
LOCATION OF STRUCTURES AFFECTED .
of septic disposal area .
*
* COMPLETE INFORMATION REQUIIREDp Eo OAhi .
* Size of property 100t plan ft X 120 ft .
Existing building ( s ) Size NIA ft x� ftr
de
PROPOSED BUILDING AND USE : Hof * Existing building (s) Use NIA
Size of new strut a 32 ft X 48 eeeeee�ft "
Foundation-pier slab crawl/partial/full * Proposed ]ouilding, seee pploot plan property line
circle one) ,� Front bard 3p+ €t Rear yard 30+ ft
Nor of stories (habitable s e)
Height (grade to ridge ) 1��b�" 1 ft . * Side yards. —ft and 15+ ft
If residential , nor of families of 2 * If on corner , setback from side street ft
No . of ooms (exclud.ing baths ) 5� " OCCUPANCY INFORMATION
Now o bedrooms 2
�' �. PRIMARY BUILDING -
Now f bathrooms 2
Primary heating system Baseboard electric* One family dwelling oon ssRae"6 DCU
Two family dwelling t �i� '
Type of ,fuel Electricity * Multiple dwelling / Number of units
No . of fireplaces to be installed Permanent occupancy
will a wood stove be installed? Na * Transient occupancy
Central Air conditioning? No
* Business
BUILDING STYLE, PRIMARY STRUCTURE Industrial
* Other
Ranch Contemporary Lo cabin If addition, what will use be?
Raised ranch Mansion Duple
split level Old style Bungalow
Cape God cottage Other '* ACCESSORY BUILDING-
Colonial Row Town House * Detached garage/one car/ two car/ car
( CIRCLE ONE PLEASE ) * _Attached garage/one car/ two car/ Ogle car
Private storage building
ESTIMATED MARKET VALUE OF ',Other
CONSTRUCTION /�� -�y d' � � r� , ef
INFORMATION ON - BUILDING SPECIFICATIONSr ON REVERSE SIDE OF THIS SHEET, TO BE COMPLETEDI
Form SPA 4/86 and-vl
BUILDING PERMIT APPLICATION CONTINUED -
BUILDING SPECIFICATIONS : +
Type of construction , wood frame , fire safe, etc .
wood frame
Will any second-hand or ungraded lumber be used? If so , for what? no
Foundation wall material concrete block Thickness 8""
Depth of foundation below grade (to bottom of footing ) 8" minimum
Will there be a cellar? no Heated or unheated? Floor sq. footage sq ft
Will there be a basement? no will any portion be used as living space?
( If so „ what port ' ? sq. ft . - - Type of use?
Type of roof - sloped flat/shed/other Material of roof Fi r ass shingles
Size , wood studs '" x 6 "" spacing 24 "o . c . length $ ft. exterior walls
Joists ( floor beams ) 1st . floor N/A '"x is spacing "o . c , span N/A ft .
JoiSts ( floor beams ) 2nd . floor -"X _ spacing Po . c . span N A ft .
Overlays (ceiling beams ) "x If spacing 24 "o . c . span N/A ft .
Roof rafters 2 "'X10.40
spaci� n- g 24 o . c . span 14 ft .
Roof trusses (pre-engineered) spacing "o . c . span 42 ' ft .
Exterior wall finish stained. Of what material? 5 /8" x 4 ' x 8 ' texture ill
Interior wall finish pain s eetrock
If a garage is to be attached , describe materials to be used for FIRE SEPARATION :
1 /2" type "X" sheetrock
Is there to be an opening between garage land dwelling? yes If so will a Fire-rated
door , enclosure , and self-closing device be provided? yes
Will a flue-lined chimney be installed? No Height alcove roof N/A ft .
Depth of chimney foundation below grade N A ft .
Depth of fireplace hearth N/A ft % inw
Water supply - Municipal or private well municipal
SEPTIC SYSTEM _ Distance from ANY private well ( including adjoining properties ft .
(A separate application is necessary for an re air or new installation of septic system)
See S . P . E . D. S , tyerftiit # 026252
Town of Queensbury County of Warren A F F I D AV I T STATE OF NEW YORx
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 .
i
SWORN TO BEFORE ME THIS Signature_ -- "cw -1t�� ..__-- _�___--------
[)wner , owner ' s agen rcnarect, contractor
day of + 19 1 EUZABETH K. LANDAY
Notary Public. State of Now York y
No. 4862001
Qualified in Saratoga County
Notary Pub Warren county , N . Y . Commission Expires June
* a t w *`-'w`�F r * � �r s x s * rt * * * t * * * * * * * �r k s. • r : r► * �r �r * * ,v ,r ar r r * r
SPECIAL CONDITIONS OF THE PERMIT :
1123 Square feet Living
240 Square foot garage - one stall
1363 '<"
@ $7 . 00/ 100 or part of
$ 5 . 00 One stall garage.
$5 . 00 _-- -- C/O permit
Total
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 .
, MOWER ALL of the following :
�, . Cocos & floor area 1123 . F •
2 . Type of heat Baseboard electric
3 . Is the building mechanically cooled ? No
4 . Percentage of area of windows and doors 11 . 8%
A . Over 16 % Only
1 . Ua 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 ?
3 . Slab on grade YES NIP
a . If YES , what is the R value of insulation around
perimeter of floor7
4 . Is basement heated ? YES NO
a . R value of insulation
5 . Type of insulation
B . Under 16ti Only
1 . R value of roof and floors exposed to ambient conditions_
R-38
2 . R value of exterior walls X100M R-23 . 5 (U. =3 . 04+ 1
3 . R value of glazed area U. =O . 3O
4 . R value of doors R--14 . 9 (U. =0 . 06)
5 . R value of floors over unheated spaces • XXXM R-30
6 . R value of slab edge insulation - unheated slab NIA
T . R value of slab insulation - heated slab 12 . 5
B . R value of heated basement/ cellar walls ( above grade ) N/A
9 . R value of heated basement /cellar walls ( below grade ) N/A
10 . Type of insulation Fiberglass
C . Controls
1 . Thermostat maximum heat setting
0 . Duct Systems N/A
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 NIA
1 . Size of hot water or cooling carryinq agent pipe
2 . R value of pipe insulation
F . Service Water Heating
1 . Performance efficiency NIA
2 . Temperature control setting maximum
G . For Swimming Pool Only
1 . Maximum heating NIA
Telephone No . ( 518) 899-9161 eyr`
( applicant ' s ignature )
taw 000M of EdL
APPLICATION FOR SEPTIC DISPOSAL PERMIT
Ref : S . P . E . D . S .
DATE September 23 / 87 permit #
New York - 0202525
MCIDEL of
LOCATION OF PROPERTY FOR INSTALLATION 36 Elizabeth Lane
Owner's Name. Guyer Builders , Inc . Telephone* ( 518) 899-9161
Address: 119 Dunning Street , Ballston. Spa , New York 12020
Installer's Name: Guyer Builders , Inc Telephone: ( 518) 899-9161
2 A, C , E, I , .I , K, L, M
Number of bedrooms (residential only) 2 � 3 F , G, H
Total daily flaw (compute @ 150 gal per bedroom) 300
Topography; circle one: Flat Rolling Steep Slope % of slope
Soil Nature: circle one* Sand Loam Clay Other / Depth: 8 ' feet +
Gsroussd Water: At what depth? unknown 8 feet +
Bedrock or Impervious Material: At what depth? urdmown feet
Percolatim test: circle one: not require required / rate rain. inch.
Domestic water saspply* circle one. Municipal Well Other
IF domestic water supply is a Well*
Separation: Watersupply from Septic absorption 4 N/A feet
* PROPOSED SYSTEM: Septic Tank gal. (minimum size* 1,000 gal.)
TILE FIELD; Each Trench NIA feet / Total system length N/A feet
* SEEPAGE PIT(S): Number of / Size each feet by feet
* Size of stone to be used # / Depth or 'Mickness feet
I P 0 R T A N T * See S . P .E. D. S .
...Please...LIST NEW EQUIPMENT TO BE INSTALLED permit & attached
# # s # * s # * # # * * s * * * * # * * # # # # * * # # * # # s # # # * * # # s # map .
(aver)
Section 1I Septic System Inspections:
A. All applications for septic system installation, alteration or repair, as
required by the Town of Queensbury Sanitary Sewage C)rdinance, shall
be submitted to the Building Department at least 24 hours before start
of construction and shall include a plot plan showing:
1.) the propoped .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 shah 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.
Co 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.
1 have read the regulations alcove and agree to abide by these anti all requirements
of the Town of Qureensbwry Sanitary Sewage Disposal C dinance.
Signature of.responsible person.
Date:
a
Town of Queensbury
Building and Code Department
Bay at I3aviland Road
Queensbury. New York 12801
(518) 792-5832
SETTLED 1763 . . . HOME OF NATURAL BEAUTY . . . A GOOO. PLACE TO LIVE
�Qif/!7 13� �, r!!F'BIZ ,9QitI'�
BUILDING and ZONING DEPARTMENT
Bay and Hayiland Road, R.D_ 1 Box 98
Queensbury, New York 12801
D BUILDING INSPECTOR ' S REPORT
NAME
LOCATION � � �' G�+ Z -
i7ate J Q
Permit No . �
APPROVED - YES NC3
Footing/Pier Forms
Foundation
waterproofing
Backfill
Framing
Roofing
siding
masonry Vene r
Rough Plumbin v.
Relief Valves
Ext . Porches
Finished Floors
Interior Trim
Stairs & Railings
Cellar Drain Tile
Concrete Floors
plbg . Fixtures
Gar , Fireproofing
Door Closers
Smoxe Detectors
Chimney
INSUL;. TIoN :
Foundation
Floors
walls
Ceiling
FINAL ELECTRIC IN sPECTION
DRIVEWAY APPRO
Final Building Survey
Next scheduled inspection (call when eady )
Remarks- Q�C }�s"rk i f ; A"" ( 45104- .
s3uildi inspector
r/86 and-vl
�pLV!'1 Of
gU1L.D1NG and ZONjt4G DEPARTMENT8
Bay and Nav3land Road, o kO12801
Queensbury, New
S PTYC DISPGSAL SYSTE�4 INSPECTION
V
NAME_ v
L_OCAT ION G �i
r PER1"�IT NO *
an LO&M _ CIaY
TYPE an YES
SOIL Test Reqlred .
Percolation race Min/ Inch
Percolation f `
TYPE of SYSTEM: total le gth
Liars field . �� -- -
pbsOxp ch trench
Leng th of tre cheep--
-Depth of
Size Of grave t� 3
SEEPAGE T5� G� t .
Size- ft. � Type
Gravel size Sizes. ,-,�, e,
PIPING Co ,tank �--""
Tax'�K to ist
l . bo
to fl Id at NO 4
Party al
Dli O 5
Openings 'Seale
LOCATxON/SE'P TIONS : ft.
Lion t tanYc Jft .
Founda O absarption ft..
/�•.1 Foundation o lot line ft.
AbsorF'txon of pits one)
5epaxatiOy PROPER (circle
IOOp TIO13 SYS t s3 cle Rig Side
Front ar
COMMI�9TS :
?,f2. SejoK
SY STFM L3 SE p.PPROVED
3uil
ing In5pectOr
dl/g and vl
p �..M -
�uQena� ar+�'
` flown o DEPPRIMEWT
SU1LI oING and xpN1fSG Box 98
i gay and 4iavl4and P►oa' � 12601
• a QueensbufV. New
INSFECTOP IS REPORT
'B l7 I L D I NG
NAME .%- 1
UOCAT ION .7e
1t NCB '
"� perm ,N
IyatE * */r �� .- --� apPROVED YES
gootin9/l'i er Farms
Foundation
Waterproofing
gackf ill
Framing
Roof ing
S id ing nrY Veneer
Masonry
Rough Pltnnlbing
Relief
Ext . porches
Finished Floors
Interior Trim
it in9 s�
stairs Tile f
cellar Drain r � -
concrete Floors --
P11309 - Fixtures �.._
Gar , Fireproof i 9_�
Door Closers
Smoke Detecto 5
chimney
4pCtSUJ.A`rION
Foundation
Floors
walls - --
Ce it in9 xi3SYECTIOt3�--- ---
FILS i E' ECTRICAI.
i1R1-VEWAV APPIZOVAsurvey
Final Building
Next scheduled insP
action (call when ready}
Remarks-
8u din4
Inspector
6/86 and-vl
oeusr 401 QlAee " Jb " y
� f
1LO1�hSG NIN DEPARTMEN
8U T
and ZC) Ga
bay )I Ha�iland Road, R.'D_ 1 Box 96
Queensbury, t.few yark 12801
U I LDING INSPECTOR ' S REPORT
Np,ME
LOCATION
1C�'I;'
�C�-LI--- permit Nr� .
APPROVED - YES NO
Footing/Pier Farms
Foundation
waterproofing
gBkfi- 13
aaming
Roo€ ing
Siding
Mar nry Vene - --- `�
�ough plumbin -
Relief Valves
Ext . Porches
Finished Floors
Interior Trim
Stairs & Railings
cellar Drain Tile
concrete Floors
Plbg _ Fixtures
Gar . Fireproofing
Door Closers
smoke Detectors
chimney
INsUTATTON
Foundation
Floors
walls
Ceilin(l
FIPIAII 1:LECTRIC L INSPECTION
ORIVEWA-Y APPROVAL 'Survey
Final 11t� ildinP
Next
scheduled inaQection (call w ready )
hen
Remarks-
BAldin ar
6/86 and-vI
0 fr BULLDING and ZONING DEPARTMENT
Pf Bay and Havifand Road. R.D . 1 pox 98
()ueensbury, New York 12801
BUILDING INSPECTOR ' S REPORT
NAME
LOCATION
Date Z.12 �- �'-�-` � Permit NOV ! ��
,r * w * * ,k * * * *I✓,�` :* APPROVED - YES *N'�
Footing/Pier Forms
Foundation
Waterproofing
Backfi. 11
Framing
Roofing
Siding
Masonry Veneer
Rough Plumbing
Relief Valves
Ext . porches
Finished Floors
Interior Trim
stairs 6 Railings
Cellar Drain 'Pile
zoeoncrete Floors
Pibg _ Fixtures
Gar . Fireproofing
Door Closers
Smoke Detectors
Chimney
INSULATION
Foundation
Floor
walls
Ceiling
FINAL ELECTRICAL INSPECTION
DRIVEWAY APPROVAi
Final Building Survey
Next scheduled inspecClon (Call when ready )
Remarks-
Bu i .Ldinrl I r�,f�e�c for
r: +fir, Nio- k— ef1
p ' .Jo w n r►
�l f � r� �Esufl.l?tNG and ZC?N1h1G t7'i=7�RTSM�x 98
SaY and HavenSbU nd N w York 12601
riJ"[ ()ueensf�ury.
INSPECTOR ' S REPORT
NAME "
LOCATION ' ll' y 1J
r� /rj Pc rmi t Nam'
Date
* *
APPROVE- - YES NO
mooting/Pier For s
Ater rOQf
f_Waterproof in9
Backfill
Framing
Roof ing
Siding
Masonry Venee
Rough Plumbing
Relief Valves
,,t, . Porches
Finished Floors
Interior Trim
Stairs & Railings
Cellar Drain Tale
Concrete Floors
Plbg - Fixtures
Gar . Fireprao rngg
Door closers
SsnoXe Detec ors
Chimney
IN SU LAT',
Foundati
Floors
walls
Ceiling
FINAL ELECTRICAL I[3SPECTIO
DRIVEW Final Building Survey
NexC scT+eduled insP
eccic�n (call when ready )
0 ,. 4 (
]3uildin9 1 pector
6/86 and-vl
�17G[l1►7 O� �4SQE+I'l ��L't1'�
BUILDING and ZONING DEPARTMENT
Bay and Haviland Road, R. D. 1 Box 98
Queensbury, New York 12801
BUILDING INSPECTOR ' S REPORT
NAME
LOCATION
Date Permit No .
✓ = APPROVED - YES NO
Fpoting/Pier Forms
LP6undation
Waterproofing
A.'Sackf111
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
Chimney
INSULATION
Foundation
Floors
Walls
ceiling
FINAL ELECTRICAL INSPECTION
DRIVEWAY APPROVAImw
Final Building Survey
Next scheduled inspection ( call when ready )
Remarks-
Building Inspector
6/86 and-VI
_../crwn o� �ueendhurt�l
BUILDING and ZONING DEPARTMENT
Bay and Haviland Road, R. D. 1 Box 98
Queensbury, New York 12801
BUILDING INSPECTOR ' S REPORT
NAME
LOCATION
Date / ermit No .
✓ = APPROVED - 'YES NO
Footing/Pier Forms. -
Foundation-
Waterproof Ing
Backfill
Framing
Roofing
Siding
Masonry Veneer
Rough Plumbing
Relief Valves
Ext , Porches
Finished Floors
Interior Trim
Stairs & Railings
Cellar Drain Tile
le.
Floors
Plbg . Fixtures
Gar . Fireproof
in
Door Closers
Smoke Detector
Chimney
IN S E]LAT I ON .
Foundation
Floors
Walls
Ceiling
FINAL ELECfTRICAE INSE'ECTION
DRIVEWAY APPROVAL
Final Building Survey
Next scheduled inspection (call when ready )
Remarks—
Building Inspector
6/86 and-vl
BUILDING and ZONING DEPARTMENT
Bay and Haviland Road, R,D. 1 Box 98
❑ueensbury, New York 12801
BUILDING INSPECTOR ' S REPORT
NAME
LOCATION
Date ` / permit Na .
✓ = APPROVED - YEr NO
Footing/Pier Forms
Foundation
Waterproofing
Backfill
Framing
Roofing
Siding
Masonry Venee
Rough Plumbing
Relief Valves
Ext , Porches
Finished Floors
Interior Trim
Stairs & Railings
Cellar Drain Ti
Concrete Floor
Plbg . Fixture ---
Gar . Firepro fing
Door Closer
Smoke Dete tors
Chimney
INSULATI
Foundati n
Floors
Walls
Ceiling
FINAL ELECTRICAL INSPECTION
DRIVEWAY APPROVAL
Final Building Survey
Next scheduled Inspection (call when ready
Remarks-
� I
BW ing Inspector
6/86 and-vl
BUILDING DEPT- COPY OF APPLICATION FORM 46-EL, NEW YORK BOARD OF FIRE UNDERWRITERS.
FILE THIS COPY WITH BUILDING DEPT. WHEN REQUIRED.
TEMP. DiA7'E
CITY OR .l.1. „�.y,�•��,.,�� y
VILLAGE '�jr�T TOWNSHIP QLumn "'^"r COUNTY �P n
STREET AND NO. OR -
ROAD AND POLE no. ; sa'I'1s71 '}3 T ,y Pp LE ND
BETWEEN WHAT TWO
CROSS STREETS IS
PREMISES LOCATE ? SECTION BLOCK LOT -
OCCUPANVS
NAME BUILDING
OCCUPANCY - !
OWNER'S NAME
AND ADDRESS �f-I eY.- Inc TEL- #
U 7
SUPPLIED . . t
BY !,�% I - FROM THEIR OFFICE
BUILDING - �-�-tIr WORK . ,. Y
IS NEW l__,Il1s OLD ❑ {g DEFECTS
NEW ADDITIONAL ❑ REMOVED C]
LIST BE LOIN ALL EQUIPMENT WHICH YOU INSTALLED
NUMBER OF OUTLETS Laawp Fischman
",a eptklK MOTORS HEATERS BRANCH
Luca- CIRCUITS OFFICE USE ONLY
ball Side Attecb't
Calling Swlteb Pendent Bracket No. T H-P.
Wall Aeap7e YM E� No. Each No.
ats GiW,;pOe- INSPECTION
Out-
side
SuR
bees
Base
maml
in FI.
2nd FI-
3rd PI.
REMARKS: LIST OTHER ELECTRICAL DEVICES NOT SET FORTH ABOVE: DO NOT USE THIS SPACE.
This appNi alion is intended to cower the above-listed equipment to be inspected but if at time of inspection them is found additional equipment not above listed,
you are authorized to make the inspection and adivat the fee to cover the additional equipment, as Provided by the apPlicant-
SIzE OF ELECTRIC SIGN
MAINS 150 �e FEEDERS LAMPS TOTAL
WATTS
CHARACTER EXPOSED GAS TUBE SIGN
OF WORK RouWb In emd service CONCEALED TRANSFORMERS OF VA
WORK TO BE {NUMBER) IC APAGITYI
STARTED COMPLETED SIZE OF SIGN
SERVICE OVERHEAD UNDERGROUND
ENTERS �op��v. MAKER
BUILDI Mao OF SIGN
INSPECTION REQUESTEDON POSSIRBLE NEAR AS WLU cAL 1. vhen ready
MESA! E1 OLD IEJ
AVOID DELAY BY GIVING FULL AND ACCURATE INFORMATION- ALL SPACES MUST BE FILLED IN OR APPLICATION MAY BE RETURNED.
PRINT NAME AND ADDRESS
NAME OF
APPLICANT_::- QrMwry ATi Ielnr-m GATE OF
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STREET ADDRESS 119 �' Street Cs�T—�ri �,
-1 TELEPHONE #
CITY OR
OFFICE Bea"1;''m �It bim York. ZIP I M20 LICENSE NO-
CODE WHEN APPLICABLE
46 EL (REV_ 1/05) A SEPARATE APPLICATION MUST BE FILEE) FOR EACH SEPARATE 'BUILDING