1987-742 "Y'R[,. y`.'. P ✓)H.H _ .vrrp `
f '� ry + v • t f .n
�ERTIFIC.A►. _F w OF OCCUPANCY
TOWN OF QUEENSSURY
WARREN COUNTY, NEW YORK
,..y J^''. Date October 13 lq 88
This is to certify that work requested to be done as shown by Permit No, 87- 742
has been completed.
'Phis structure may be occupied as a
One Family Dwelling
t" , #r ? Queens Diana Lane
Location
Owner D . E . C . Develop rent
By Carder Town Board
TOWN OF QUEENSBURY
Building & 31ni ifispectar
` BUILDING PERMIT �
TOWN OF QUEENSBURY �
No. 87-- 7 42
WARREN COUNTY, NEW YORK
cc
PERMISSION is hereby granted to D . E . C . Development W
1
OWNER of property located at
Lot # 7 Queen Diana Lane Street, Road or Ave. ~
in the Town of Queensbury, To Construct or place a One Family Dwellinix
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.
a
t. OWNER'S Address is m
184 Dunsbach Rd .
Cohoes , N . Y .
a
m
2. CONTRACTOR or BUILDER'S Name C
Same O
�s
EB
ro
D
3. CONTRACTOR or BUILDER'S Address rt
4. ARCHITECT'S Name
r
rt
to =
5. ARCHITECT'S Address w
C
o m
o m
CIA 0
6. TYPE of Construction — (Please indicate by XI {'' t7
� r
[a W
k3j Wood Frame I ) Masonry 11 Steel f ? m P
r
7. PLANS and Specifications
tv
No 32 ' x 48 ' per plot plan , specifications and application including Y
septic system, attached two Car garage .
s. Proposed Use One Family Dwelling
ro
,zy
$5 . 00 C/O H
$ 150 . 00 PERMIT FEE PAID — THIS PERMIT EXPIRES May 1 , 19 88 �
r
(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 date.)
Dated at the Town of Queensbury this y30th Day of October 19 87 ago
SIGNED BY /'' •" / � /'LY 1 for the Town of Queensbury
Building arW Zo ning Inspector ;'
TO BE COMPLETED BY BLDG . DEPT .
Application No . 1
D/ Quee+n3fi "ry Permit Issued 19
TOWN OF QUCCLN`,j
BUILDING and ZONING DEPARTMENT Permit Expires
Bay and Haviland Road, R. D. 1 Box 98 Zoning Designation
Queensbury, New York 12801 Variance No. p+ p # p LU
a
�] Site P
IReview 1�Igy" 1 ULT 2 8 19U7
✓ Appro MAPPLICATION FOR
EUILDING AND ZONING PERMIT Lt
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 ; , _ _ice 1 [ LrO/102Me +Ll1► �> �tmn
P . O. Address / ?� JJrrLr1C� ry^. � �A "C J7 Te1 . 2+ S"a / �
Property Location : L f I � ar �7�c !,ry .VigryA Ln7 Tax Map
Street number or building lot number
Subdivision name ( if applicable) a aQ I a;�'.�t&. !=A cJos �
THE PERSON RESPONSIBLE FOR SUPERVISION OF WORK AS REGARDS BUILDING CODE'S IS :
T�_ "1 Ave C04eurse0 <4 to" ( �? 4' $R-O639
Name P . O . Address Tel . No .
Name: of builder �—S�Aewe; 'SIS +�cx +: Address Tel .
Name of plumber v" C f' lu.n41:3 Address i SCa GfL,dFo ( T !fit --- Tel . - -
Name of mason /j ►9V (`v CC>Lv� kC'"T' Address T "w Ds r �rs.r Tel . +'i 3- Sf
NATURE OF PROPOSED WC)RK : * ZONING INFORMATION :
L0 Constructi.on 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 building's ,
(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 l!-ft X r ft .
Existing building ( s ) Size — ft X 1 £t .
*
PROPOSED BUILDING AND USE : * Existing building ( s ) Use
Size of new structure ft X
Foundation-pier/slab/crawl/partial ul Proposed building , distance from property line
(circle one ) * £t Front yard lnC3 ft Rear yar
He of
/ D } ft
No . of stories (habitable space) �. * _^�� ft and G C2.
Height ( grade to ridge) 'a C7 ft . * Side yards if on corner , setback from side street — ft
If residential , no . of families I
Now of rooms (excluding batr 7 * OCCUPANCY INFORMATION
No . of bedrooms "
PRIMARY BUILDING -
No . of bathrooms - - -- ,
Primary heating system _eOne family dwelling
e of fuel * Two family dwelling
Tip Multiple dwelling / Number of units
No . of fireplaces to be installed
Will a wood stove be installed? Nov * Permanent occupancy
Central Air conditioning? KP4=� * Transient occupancy
* �ESF,1S2rteSS
BUILDING STYLE, PRIMARY STRUCTURE * Industrial
Ranch Contemporary Log cabin * Other-
Raised ranch Mansion Duplex * If addition , what will use be?
Split level Old style Bungalow
Cape.Qod Cottage Other * ACCESSORY BUILDING-
olon '' ' Row Town House * Detached garage/one car/ two car/ car
( CIRCLE ONE PLEASE ) " _/Attached garage/cane car/ a car car
Private storage building
ESTIMATED MARKET VALUE OF * Other
CONSTRUCTION
7ToFORt•1ATION ON BUILDING SPECIFICATIONS , ON REVERSE: SIDE OF THIS SHEET , TO BE COMPLETEDI
Form BPA 4/86 and-vl
BUILDING PERMIT APPLICATION CONTINUED -
BUILDING SPECIFICATIONS :
Type of construction , AEod frame fire safe , etc .
Will any second-hand or ungraded lumber be used? If so , for what ? rL.? C)
Foundation wall material " ,nx fC T Thickness Jew
„t�
Depth of foundation below grade (to bottom footing )
Will there be a cellar?-�/, Heated or eated7 Floor sq .--footage / ,� e� sq ft
Will there be a basement? c1aC�{nTill any no
ion be used as living space?
( If so , what portion? sq . ft . - - Type of use?
Type of roof - slopeT,6g
at/shed/other Material of roof SIJ, �„� L
Size , wood studs spacing It, "o . C . length ft . "-"--
.joists ( floor beams) 1st . floor _ "x /CD IF
spacing /c> '"o . c . spanoja, 5fft ,
Joists ( floor .beams ) 2nd . floor Pox.....�11 spacing / b '0o .
Overlays (ceiling beams ) FIX No spacing "o . c . span ft .
Roof rafters W & spacing J40, o , c , spun (v ft .
Roof trusses (pre-engineered) spacing�y�"o . c . span (�ft .
Exterior wall finish , ., Of what material?
Interior wall finish�,r 2E ,�j,t
If a garage is to be attached , describe materials to be used for FIRE SEPARATION :
_ 1FrVac Ce INS 7Itoc k.
Is there to be an opening between garage and dwelling? if so will a Ei
re-rated
door , enclosure , and self-closing device be provided? f7&:_E_L5
Will a Flue-lined chimney be installed? ktL: C) Height above roof — ft .
Depth of chimney + foundation below grade rVA/ ft ,
Depth of fireplace 2aejarth ft . in .
Water supply unicipa or private well
SEPTIC SYSTEM _ tance from ANY private well ( including adjoining properties ft ,
(A separate application is necessary for any repair or new installation of septic system )
Town of ffu ry
County of Warrenarren K.A F F I D A V I T STATE OF NEW YOR
3 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 HIIILDING 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
C7wner , owner ' s ag , arcnicect , contractor
of 19
Notary Public , Warren County , N . Y .
* * * * * * * * * * * * * * * * * * * * * * * * * * * * r * * * * * * * * * * * * * * * * *
SPECIAL CONDITIONS OF THE PERMIT :
By-
................
r
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 : y
1 . Gross floor area pCx�
r
2 . Type of heatt � Tk' � C
3 . Is the building mechanically cooled ?
! oo
4 . Percentage of area of windows and doors lC
A . Over 16 % Only
wow
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 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
S . Under 16 % Only
1 . R value of roof and. Voors exposed to ambient conditions
_ , '3
2 . R value of exterior walls
3 . R value of glazed area
4 . R value of doors
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 IVA
8 . R value of heated basement / cellar walls ( above grade )
9 , R value of heated basement /cellar walls ( below grade )
10 . Type of insulation
Co Controls
1 . Thermostat maximum heat settingyLR �
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
2 . R value of pipe insulation
F . Service Water Heating 8
1 . Performance efficiency
2 . Temperature control setting maximum
G . For Swimming Pool Only
1 . maximum heating
Telephone No . / :57 63,9
( applica is ' gnature )
- � u ►� �� ��u y APPLICATION FOR SEPTIC DISPOSAL PERMIT
BUILDrNG and ZONING DEPARTMENT
Bay anc Hav,land Road, A.D. 1 Box 984
Queensbury, 1Ven York 12801 d
/ DATE
LOCA710N OF PROPERTY FOR INSTA- LLATION �c�7r # I r �dXCW � lczS�
OWNER ' S NAME �- ��'s �� ccfC��r�"��w
ADDRESS
INSTALLER * 5 NAME � TEL
Number of bedrooms ( residential only)
Total daily flaw ( compute @ 150 gal per bedroom ) /rC? b
Topographye Rolling - Steep slope - ( circle one) % of slope
Soil nature : - Loam - Clay - Other Depth ft .
Ground water -At what depth? /t)orUe ft.
Sed-rock or impervious material -- At what depth? IU4DrVk ft -
.Percolation test 3ac3�require5L - Required - -Rate min-inch .
Domestic water supply Runic p Well - Other
Separation - ►+vatersupply ( if well ) from Septic absorption I "i' ft ,
Proposed System : Septic tank /Oo (D gal . ( 'Minimum size , 1000 gal . )
Tile Field - Each trench .5) ft . Total syste;ri legnth a6'1D9 ft .
Seepage pit ( s ) Number of Size each ft Y ft
Size of stone to be used Depth or thickness ft .
IMPORTANT ! !
On a separate piece of paper , subyait a diagram of the proposed system
with all dimensions 'shown ; including distance from any structure ,
distance from property lines and from ANY DOMESTIC WATER SUPPLY or
shore - line of lake , stream , pond or wet - lands. ' Include all dimensions of
r
the system , itself .
1' Y. .:.' L' e.- ] • C. .: c: Y. i:. i }' E �.• :.: "� e`. ; ? 1. F GY. 7 'r; C ?"� .' CY• EE .r, iL: £ Cif 7. +�': i. S L CC cr: :.' C, G ?`Cc
to abide by t } Esc ar. d a71 requirements cf The Tor.*n of Quee -neburxy
Scr. itor;: 56L: 00e Lisposci ordir< ancc .
.Sioncture of resronril. le rerLor.
05 / 8 +6 and / ul
Section IT Septic Systnm Tnspections :
A . All applicationd for septid system installation ,
alteration or repair , as required by the. Town of
4ueensbury Sanitary Sewage Ordinance, shall be
submitted to the Buildina 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
D . 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 e1
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 worts 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 Oueen sbury► Sui ld ina %
Departanent before further construction .
• ! Y
4002343 THE NEW YORK BOARD OF FIRE UNDERWRITERS
BUREAU OF ELECTRICITY
to 41 STATE STREET. ALBANY* NEW YORK 12207
Date October 17 , 1988 Application No. on file 0 3 2 a 4 0 /f 8 6 � 730926
THIS CERTIFIES THAT
Only the electrical e9++iptrrent as described below and introdasced by the applicarst namod on the above applications number in the premises of
DEC DevelopeamtnLot # 7 - 14 Queen Diana Lane Queensbury , New York= dwell
in thefellowins facation; XD Basement ® Iat Fl. 'U 2nd F7. garageoutss ide Section Block Lot
coos ezansinedon 1 , $ end,fPand to be in compliance with the requirements egenirementa of this Board.
FIXTUOUIL E EMACWES SWITCHES FIXTURES RANGES COOKIN4O*CKS OPENS blStf WASHERS EXHAUST FANS
T�T"S' �L q HACA"XSC(NT FLUOREtSCENT AMT_ K. W. AMT. K. W. AMT. K.W. AMT. K. W. AMT. H• P.
23 41 26 2 2 1 05 rr
DRYERS FURNACE MOTORS FUTURE APFUANCE reEa11RS SP*aAt RWVT TIME CLOCKS EEI4 UNIT HEATERS MULMOUTUET p�
AMT. K. W. OIL H. P_ GAS H. P. AMT. NO. A. W. 6- AMT. AMP. AMT. AMPS. TRANS. #AI F. H. P. SYST�S AMT. WATTS
No. OF FEET
50
1 £r 1 30 la / 1
SERVICE vW000FN *CT No. or S E R
ERe V 1 C
MA7. AMP. 1 .a ?W T eX3W Se a iFCCCpND. E
Na. CJIF NI-LEG •, NO. OF NEUTRALS GF EUTGIt'AL
1 2oo panes 1 x 2 / 0 / 0
OWNER APPARATUS:
Elec . water Heaters 1 - 4 . 5
3-grci receptacles
1 - smoka detector
mm
Richard Rosetta
423 New Karner Rd .
Albany ? NY 12205 BRANCH MANAGER
This certificate must not be akered 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 ZONING DEPARTMENT
Bay and Haviland Road, R. D. 1 Box 98
Queensbury, New York 12801
BUILDING INSPECTOR ' S REPORT
NAME
LOCATION
Date- � Permit No . Fl
- S
Footing/Pier Forms APPROVED No
Foundation
Waterproofing
Backfiill
+'Framing
Roofing
Siding
Masonry Vene r
Rough Plumbin
Relief Valves
Ext . Porches
Finished Floors
Interior Trim
Stairs & Railin s _
Cellar Drain Tile
Concrete Floo s
Plbg . Fixtur s
Gar . Firepr ofing
Door Clos s
Smoke Det ctors
Chimney
INSULAT oN :
Founda on
Floors
Walls
Ceili
FINAL ELECTRICAL. INSPECTION
DRIVEWAY APPROV
Final Building Survey
Next scheduled inspection (call when ready )
Remarks--
// .' •is
r {-
Builidingng Ins ecto
6/86 and-vl L.
_..I'ncvn a� �ueens6urt�
BUILDING and ZONING DEPARTMENT
Say and Hawiland Road, R.D. 1 Box 98
Oueensbury, New York 12801
SEPTIC DISPOSAL SYSTEM INSPECTICNV
l WE
LOCAT I CNd a,] eo
DATE r 0 P FtM ;���� [�/f ✓_ �/
SOIL TYPE - an Loam - Clay
Percolation Required? YES NO
Percolation rate - Min/Inch
TYPE of SYSTEM:
Abs tiara field, total ength
Leogth of each trench Q
Depth of trenches
Size of rave]:_
SEEPAGE TS4NUmb r of) _
Siz t. X ft.
Gravel size
PIPING, : Size Type
Bldg to to [ p I/ (r'
Tank to di b x 41 * r
Dist . box o fie / Lf ul
Openings Baled? YE NO Partial
LOCATIO /SEPARATION
Founda ion to tanker ft.
Found ion to absorpti n ZK:ft .
Absor tion to lot line eft .
Sepa ation of pits ft.
IOCA I� STRXLef ON de PERight side one )
Fro Fte��r Left side Flight side -
C
SYSTEM USE APPROVE Y N
Bu c1 Inspector
01 /86 and vl
._lvwr� o� �uep'+'3 #rurt�r
BUILDING and ZONING DEPARTMENT
Bay and Haviland Road, R,D. 1 Box 98
Queensbury, New York 12801
BUILDING INSPECTORS REPORT
NAME
LOCATION
Date e^i
�?/ Permit
* * * * * * * * * * * * * * * *
* * * *
Footing/Pier Forms ✓ APPROVED - YES NO
Foundation
WaterProofing
Backfill
4�r'rami ng
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 ELE TRICAL INSPECTION
DRIVEWAY PPROVAI
Final Du lding Survey
Next ache uled inspection (call when ready )
Remarks-
Buildingtsr��ao
ct,or
'�/$6 and-vl
Jncvrl o uQensbf airy
BUILDING and ZONING DEPARTMENT
Bay and Haviland Road, R. O. 1 Sox 98
Oueensbury, New York 12801
BUILDING INSPECTOR ` S REPORT
NAME
� 'J''" I
LOCATION
Date �� s j /., Permit No .
✓ = APPROVED - YES No
Footing/pier Forms
4JP6Undation
Waterproofing
8ack£ill
Framing
Roofing
Siding
Masonry Veneer
Rough Plumhing
Relief Valves
Ext . Porches
Finished Floors
Interior Trim
Stairs & Railings
Cellar Drain Tile
Concrete Floors
Plbg . Fixtures
Gar . Fireproofing
Door Closers
Smoke Detectors
Chimney
INSULATION :
Foundation
Floors
Walls
Ceiling
FINAL ELEC RICAL INSPECTION
DRIVEWAY A PROVAL
Final Buil ing Survey
I
iVext sciceduled inspection ( call wlxen ready )
Remarks-
r yZAO
P �T-
Buil Inspector
6/86 and-vl
,_..pawn v� q�ueen3hure�
BUILDING and ZONING DEPARTMENT
Bay and Havitand Road, R.D. 1 Box 98
Queensbury, New York 12801
BUILDING INSPECTOR ' S REPORT
NAME
LOCATION�
Date
��� Permit No . L L 749
r ✓ APPROVED - XE9, 1,1NO
ting/Pier Forms
VV Foundation
waterproofing
Backfill
Framing
Roofing
siding
Masonry Venee
Rough Plumbing
Relief Valves
Ext . Porches
Finished Floors
Interior Trim
Stairs & Railings
Cellar Drain Til
Concrete Floors
Plbg . Fixtures
Gar . Fireproof ' g
Door Closers
Smoke Detecto s
Chimney
INSULATION :
Foundation
Floors
walls
Ceiling
FINAL ELECT CAL INSPECTIOPI
DRIVEWAY APPROVA1•_
Final Building Survey
Next scheduled inspection (ca) l when ready )
Remarks- �.►^
I
Buildin Inspector
6/86 and-Vl
BUILDING DEPT. CO FI Or LLE THIS COPY 1 IRE UNDERWRITERS.
W, H BUILDING DEFT WHEN REQUIRED
f 7. ,1,E ? ? !F : -•"�
r F
CITY OR COUNTY
VILLAGE4� 1 F-. f [J S4' TOWNSHIP 1/It�
STREET AND ND. QR POLE
ROAD AND POLE NO. /
BETIYEEH YVHAT TWO _ Ft f a K Jy LOT
CCROS'SSTREEYSTED - ! ' • � -- �:E '�V f ` E PION
BUILDING
OCEUPANT#$ d0 _ A OCCUPANCY 11
OM/RER"S NAME ..r ram' 1_I{ ,I,y
AND ADDRESS T I ram- f
OFFICE
FROM THEIR
SUPPLIED �"' f �''�� Gw,i DEFECTS
MARK
BUILDING - NEW ADb1TkONAL ❑ REMOVED
IS
NEW OLD IS
LIST BELOW ALL EQUIPMENT WHICH YOU INSTALLED
BRANCH OFFICE USE
No. of Fiwiurr b MOTORS HEATERS GRCUITS ONLY
NUMBER OF OUTLETS Lanw RwaPtod�
1 H.P. Na. Ea h No. AGauge INSPECTION
tion Sis wh paFafant BFskat No. TYPO Each
OailCollinsWa1I Raoap'k
Dot-
aida
Sub
base
saw
mant
its FL
tad FI
3Fd Fl.
DO NOT USE THIS SPACE.
REMARKS. LIST OTHER ELECTRICAL DEVICES NOT SET FIRTH ABOVE :
is 100"
This appliaatian is intandad to cover t ab i adiutod O foanin oto btt+a add+d+1 9u butiPma�aoo ProvkWel by Vha aPPlivat. itionsl s4akWaartt not s6ova liztod,
yuai we w.thwised to make thus irNP"c ELECTRIC SIGN TOTAL
S12E OF FEEDERS LAMPS WATTS
MAINS EXPOSED GAS TUBE SIGN
CHARACTER TRANSFORMERS OF VA
qq � CONCEALED-�--� IGAC I T V)
OF WORK /{./ Cr ' AP;NUMBER)
WORK TO Be e) COMPLETED 512E OF SIGN
J
STARTED i UNDEfIG"OUND MAKER
ENTERS OVERHEAD OF SIGN
I t Mr. F OLD Q
INSPECTION REQUESTED r
PO SI AS NEAR AS �,,� . r �- C
POSSIBLE �{
AVOID DELAY BY 61 VIMG FUL4 ANO ACCURATE INFORMATI6N. ALL SPACES ,APPLICATION _—
-
MUST BE FILLED IN OR APPLICATION MAY BE RETURNED. _ _ SIGNATURE
PRINT NAME---���pp ���]yyy D ADDRESAt� �_ I �� Y —^=—
NAME OF r��J ,f [, F APPLICANT .=------'—
APPLICANT _ /
S TELEPHONE #
f € f ,�''r_:eta •, i :r � , �,�.
STREET ADD"ESS ZIP
i 1J{- :i:�•- !. LICENSE NO,
CITY OR f r - CODE WHEN APPLICABLE
POST OFFICE `-' � ! r"" -'
as EL (REN- +Ias) A SEPARATE APPLICATION MUST BE FILED FOR EACH SEPARATE BUILDING
I I I
1 at
I -
I I {
l_
jq
I
. - - - - - -
_ - - - - I � - I _ram
j
p I -
: Cs I I -
i
.-� n
I
fi � V
i r _
I
' I
I � Q
I
I
i
i
Q 1 ,1 L^j