1987-765 r
CERTIFICATE OF OCCUPANCY �
TOWN OF QUEENSSURY
WARREN COUNTY, NEW YORK
Date June 273
19138
1 1
~_ F37 -765
This is to certify that work r Quested to be done as shown by Permit No.
I
has been completed.
one Far^ily Dwelling
"Kris structure may be occupied as a
25 Hidden Hills Drive
1,ocation
Mike Turner
j Owner
i
By Order Town Hurd
TOWN OF QUEENSBURY
i
1
Building lespactni
I
I
BUILDING PERMIT �
TOWN OF +QUEENSBURY No,
WARREN COUNTY, NEW YOR K
a
Mike Turner g
PERMISSION is hereby granted to 1
Street, Road or Ave. i
OWNER of property located at Lot
in the Town of Queensbury, To Construct or place a
One 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.
# . OWNER'S Address is 38 Rogers St .
Apt * C 'J
Glens Falls , N . Y . 12801 ro
�-a
2_ CONTRACTOR or BUILDERS Name
John Heath 'O
rs
3. CONTRACTOR or BUILDER'S Address
RD 1 Box 1219
Whitehall , N . Y .
r
a. ARCHITECT'S Name o
N
1-�
g• ARCHITECT'S Address
M
S. TYPE of Construction — (Please indicate by X) to r
F�
Cfl SA
{ Wood Frame { } Masonry i I Steel
G
7. PLANS and Specifications tr
to
r ectfications and application Y•
No. 2$ x 54 as per plot plan , sp
including spetiC �.411-9WO system, attached two car garage and driveway perm t �j
S. Proposed Use
One Family Dwelling
0
lD
ro
$5 . 00 CIO ,Tune 1 ,
$ 157 , 00 PERMIT FEE PAID — THIS PERMIT EXPIRES pi
lif a longer period is required an application for an extension must be made to the Building and Zoning inspector of the dN•
town of QuaensburV
before the expiration date.) C
16th November 19 87
Dated at the Town of Queensbury this Ray of
r
(,r��.� wJ for the Town of Queensbury 0
SIGNED SY — ac
Building and Zoning lnap4e
TO BE COMPLETED BY BLDG , DEFT .
Application Noe
_ 70ty" ar� �it ¢erea6ur( Permit Issued 19 _
19 i r i � �
BUILDING and ZONING DEPARTMENT Permit Expires ��
Bay and Haviland Road, R-D. 1 Box 98 Zoning Designation �# f� { I.
Queensbury, New York 12801 Variance No . NOV87
Site Plan Review Noe
Approu,e - by :
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 :
P . o. Address [?
Tax Map No
Property Location :
C ( 1 G�
Street number or budding lot number
;
Subdivision name ( if applicable) u , z2e_ t�24�
THE PERSON RESPONSIBLE FOR SUPERVISION OF WORK AS REGARDS BUILDING CODES IS : f
Tel . No .
Name P . O . Address -_:
Name of builder . / / fir ! Address r G,_ rd�.�rr Tel .
r Tel .
Name of plumber �{ y + Address / Tel .
Lam, 3 " J' AddressJ�r �r� '= � . c �Gr�
r' Y
Name of mason :/-fin yr _
NATURE OF PROPOSED WDRK : * ZONING INFORMATION :
f ` construction of a new building
A PLOT PLAN MUST BE PREPARED AND SUBMITTED
Addition to a building drawn reasonably to scale and attached hereto ,
_
* showing clearly and distinctly all buildings ,
Alteration to a building
(no change to exterior dimensions ) * whether existing or proposed and indicate all
het--back dimensions from property lines _ Give
Other work (describe)
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 . r
* Size of property_�,,.,�44
r ft X $ ft
" Existing building { s) Sized �f't Xft .
*
PROPOSED BUILDING AND USE : * Existing buildings ) Use r�
Size of new structure
r* --f t X�f t
Foundation--pier/ slab/crawl/partial/ ull Proposed building , distance from property line
ft
(circle one ) f / Front yard , 3 ft Rear yard .
Noe of stories (habitable space ) } I � Side yards ►=fez ?� ft and ,y� l- ft
ft . fit
Height (grade to ridge) � .'�` If on corner , setback from side street
if residential , no . of families * OCCUPANCY INFORMATION
}� No . of rooms ( excluding baths )
ia=
No . of bedrooms _ PRIMARY BUILDING -
No . of bathrooms — 7X One family dwelling
Primary heating system 9 } * Two family dwelling
Type of fuel /� S` ,� Multiple dwelling / Number of 'units
No . of fireplace-s to be installed 9v Permanent occupancy
Will a wood stove be installed?_,4_1 r Transient occupancy
Central Air conditioning?J
BUILDING STYLE, PRIMARY STRUCTURE Industrial
Other
Ranch Contemporary Log cabin *Duplex If addition , what will use be?
Raised ranch Mansion p *
3 lit level Old style Bungalow ACCESSORY BUILDING-
-e p ti Cottage Other two car/ car
Col- Row
Town House * Detached garage/one cart
( CIRCLE ONE PLEASE )
* x Attached garage/one car/ Ewa car/ ca=
Private storage building
ESTIMATED MARKET VALUE OF Other
CONSTRUCTION
ON REVERSE SIDE OF THIS SHEET , TO BE COMPLETED !
INFORMATION ON BUILDING SPECIFICATIONS .
Form SPA 4/86 and-vl
BUILDING PERMIT APPLICATION CONTINUED -
BUILDING SPECIFICATIONS :
Type of construction , wood frame , fire safe , etc .
Will any second-hand or ungraded lumber be used? If so , for what ?
Foundation wall material_
Thickness
Depth of foundation below rade (to bottom of footing ) '
Will there be a cellar? N jt-. Heated or unheated? !': . /c ` Floor s
Will there be a basement . Will an —fit l q. footage ?�-sty sq ft
( If so , what v _ Y Portion }7e used as living space ? y,q
Po r sq. ft . - Type of use?
ZYPe of roof - 'sloped flat/shed/other Material of ryof
Size , wood studs "X_�Q:L. " spacing /i'o . c . length
Joists ( floor beams ) lat . floor r' "X rl� spacing Z fir '"o . c . span_�r _ft _
Toists ( floor beams) 2nd , floor �_ "X ,.2L spacing l r,^ "'o . c . span _ft .
Overlays (ceiling beams), 7 '+X f�" spacing` /s "o . c _ span_ f�f t .
Roof rafters ?- "'X�/� " spacing / �.`a . c . span_,�j� _ft .
Roof trusses (pxe-engineered) spacing. O . C .'" span . V ft . [ i -
Exterior wall finish LJ: f c. �_ Of what material ?
Interior wall finish
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 he provided? 7jIt . S_
Will a flue-lined chimney be installed? / 1 ' [.� Height above' .roof ft .
Depth of chimney foundation below grade 1y ZZ�E-t .
A
Depth of fireplace hearth ,y✓ /�t . in .
water supply - Muria iparor private well
SEPTIC SYSTEM _ Distance from ANY private w�ell ( inclu ing adjoining properties ft .
(A separate application is necessary for any repair or new installation of septic system )
Town of Queensbury
County of Warren A F F I D A if I 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 _ _ _ �-
Own , owner ' s agent , arcnicect , 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
2 . Type of heat
l7F JP'
3 . Is the building mechanically cooled ?. �' � '
4 . Percentage of area of windows and doors
A . Over 16 % Only
1 . Up value of gross area of walls , roof / ceiling and floors
exposed to ambient conditions
2 . Floor over heated spaces YES NO NO
a . Are foundation walls insulated ? YES
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 ?
4w is basement heated ? YES NO
a , R value of insulation
5 , Type of insulation
B , Under 16 % Only
1 . R value of roof and floors exposed to ambient conditions
2 . R value of exterior walls , J/7
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
70 R value Of slab insulation - heated slaby
$ . R value of heated basement/ cellar walls ( above grade )
�.
9 , R value of heated basement/cellar walls ( below grade )
10 . 'Type of insulation C `
co Controls e
1 . Thermostat maximum heat setting
D . Duct S stems YES NO
1 . Is duct system installed in unheated spaces ?
a . If YES , R value of duct installation f
b . R value of duct in other areas
E . Piping Insulation agent pipe
1 . Size of hot water or cooling carrying
2 , R value of pipe insulation
F , Service Water Heatin
1 , Performance effi. ciency � j
2 . Temperature control setting maximum
G . For Swimming Fool Only
1 . Maximum heating
Telephone No .
-- ( applicant ' s signature )
11
�+aurn 4f QCMAOr
APPLICATION FOR SEPTIC DISPOSAL PERMIT
DATE 1 1 / , -7
LOCATION OF PROPERTY FOR INSTALLATION
Owner's Name: / ,,� U �' �` Telephone: " 6 4/ I -3
Address: �J der cz, <; T ��Ei�.S 91�G'S
Installer's Name: arA/✓r�� �'Y Telephone:
Number of bedrooms (residential only)
Total daily flow (compute @ 150 gal per bedroom) zlyo
Topography. circle one: Flat Rolling Steep Slope % of slope
Sail Nature= circle one< Sand I Loam Clay Other / Depth: feet
Cxround Water: At what depth? % feet
Bedrock or Impervious Material: At what depth? i feet
Percolation test= circle one: not required required / rate min. inch.
Domestic water supply: circle one Munieipell Other
IF domestic water supply is a Well: feet
Separation: Watersupply from Septic absorption
PROPOSED SYSTEM: Septic T..a��nk �/, /� p� gal. (minimum size: I ,000 gal.)
TILE FIELD: Each Trench Zy Aeet / Total system length feet
SEEPAGE PITS) : Number of / Size each feet by feet
Size of stone to be used # _ �� / Depth or Thickness feet
IMPORTANT
...Please...LIST NEW EQUIPMENT TO BE INSTALLED
(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:
l .) 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 $2SO.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,
of the Town ve read the rations above and. agree to abide by these and all requirements
Queensbury Sanitary Sewage Di
sposal Ordinance.
Signature of responsible person: l
]date: ZY
! l
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
fi
4 ,001121 THE NEW YORK BOARD OF FIRE UNDERWRITERS
� BUREAU OF ELEGTRIGMY
`' -
I 41 STATE STRE ET, ALBANY. NEW YORK 12207
Date Ju 1 y 7 F 1988 Application No. on file 1 d 4 8 Q 8 / 8 7 A 7 r�? 10 5
TmiS CERTIFIES THAT
only the electrical equw' nsent as described beloro and introduced by the eppilcent newsed on the abode application nonshor in the prvensieee of
Mike Turner Hills DrIVO Queensbury , New York one fami*y dwelling
in the folk Keing location: W basement � let FY. U 8nd Ft# out s IslaiaQ 3 Block 5 Lor
was examined are 6 - 2 4 — 8 8 and found to be in compliance with the requirwrnents of this Board.
FIXTURE RCEFTACYES SWITCHES NXTURES RANGES COOKSTAP DECKS OVENS DISH WASHERS ExHAUST FANS
CUTLETS INCANDESCE'N7 n NT AMT. K. W. AMT. K. W. AMT. K-W, AMT. K. W. AMT- N. P.
18 43 21 16 2 4ramT
8 3 fr
PRYERS FURNACE hWTORs FUTURE AFFt.TANCR FEEDERS SPOCML REIC'FT TIME CTACKS REI,I, UPMT HEATERSMitIT DIEAMERS
S
AMT- K. W. 04 H. P. GAS H. V, AMT. NO. A. W. G. AMT. AMP. AMT. AMPS. TRAM;- AMT. H, P. Iy,a, CF t T AMT, WATTS
0
BFRvXM DISCONNECT NO. OP S E R v I C E
AMT. AMP. TYPE MITER 1 X 4W 1 X 9�N 3 X 3W 3 X 4W �. '�. C��' ti W. G. No. aP HI-LEG f'- W' 0 NG- OF NEUTIAL5 A. EL G.
Et LW. PER AP OF CC- G15fJD. OP HI-tEG al' NEU711AL
ado ,~b 1 4 / 0 � °
OTHER AFFARATUS:
ilea . Room Henterax 3 / 2 . 9P 4 / 1 . 5F 2 / 1 . 0P 1 / . 5
3"gfc i
1-srnO}ce cletec �C+z`
John xeath Or .
RD 1 Box 1219 239 DRANCM MANAGER
whit.eLhall P NY 12887
Prr
This certificate most not be altered in any manner; return to the office of the Board if incorrect. Inspectors may be identified by their creden%ak.
COPY FOR BUILDING DEPARTMENT. THIS COPY OF CERTIFICATE MUST NOT BE ALTERED IN ANY MANNER.
f
._..!Dorn cr� �ueen96cere�
BUILDING and ZONING DEPARTMENT
Bay and Haviland Road, R. D- 1 Box 98
(?ueensbury, New York 12807
BUILDING INSPECTOR ' S REPORT
NAME TI I LS
LOCATION
Date-Z—d? L _ Permit No .
✓ = APPR EIS - YES NO
FootingfPier Forms
Foundation
Waterproofing
Backfill
Framing
Roofing
Siding
Masonry Ven er -
Rough PI b ng
Relief Valve
F.xt . Porches
Fznished Floo
Interior Trim ✓
Stairs � Rai i s
Cellar Drain Ti
Concrote Fl or,
t�lbg . Fa t e, L oe
Gar . Firep oofing
Doer Clos s
Smoke Dot ctors
C'himne}r
INSULA'rIt
Foundati
Floors
Walls_
Ceiling
FINAL F. ECTRICAL INSPECTION.
DRIVEWAJ APPROVALti
Final 8 lding Survey
Next sche uleed inspection ( ca l when ready )
Remarks--- A7 /
�,rI7 Jt�F4� !rOOX-r I.•� S@ J7rGse17 �tiPdfr�.r
Build g spector
f/t36 rnc3-vI
p Jourre a Queenihury
BUILDING and ZONING DEPARTMENT
Bay and Haviland Road, R. D. 1 Box 98
Queensbury, New York 12801
ILDING INSPECTOR ' S REPORT
NAME
LOCATION � / _--7����
/ cC•�Permit I3o . / — //✓t!o
✓ = -
Footing/Pier Forms APPROVED YES NO
Foundation
Waterproofing
Backfill
Framing
Roofing
Siding
Masonry Veneer
Rough Plumbing
Relief Valves
Ext . Porches
Finished Flora
Interior Trim
Stairs & Railin s
Cellar Drain Til
Concrete Floors
Plbg . Fixtures
Gar . Fireproofing
Door Closers
Smoke Detectors
Chimney
vI3 SLJ EAT ION
Foundation
Floors
Walls
Ceiling g
FINAL ELECTR AL INSPECTION
DRIVEWAY APP VAIN^_
Final Builds g Survey
Next scheduled inspection (cal when ready
Remarks-
1 ng Inspector
6/86 and-vl
BUILDING and ZONING DEPARTMENT
Bay and Haviland Road, R. D. 1 Box 98
Queensbury, New York 12801
SEPTIC DISPOSAL SYSTEM INSPECTION
NAME
LOCATION/�t'^�-`-��.s.�-.C_�t�.t�t�-
DATE � PERMIT NO.
SOIL TYPE - Sand - Loam - Clay -
Percolation Test Required? YES NO
Percolation rate - Min/Inch
TYPE of SYSTEM:
Absorption field , total le gthG
Length of each trench
Depth of trenches
Size of g avel_
SEEPAGE P TS4Number o }
Size- ft. x _ t ,
Gravel si e
PIPING ; S III it III e,
Bldg . to to k �,� Type ,
Tank to dis b x 4
Disto box to . f eld/ t - -
Openings seal d? S
LCICAT.TON/SE RA IONS
Foundation o t k to
Foundatio to abs ption �t.
Absorptio to lot ne ft.
Separati ,.etf. pits --ft.
LOCATION "`SYSTEM ON ROPERTY (circle one)
Front -- ear - Left sid
CCMMENT Right side
SYSTEM USE APPROVED €Y S NO 7.
i
Bull ing Inspector
01/86 and vl
_ Joni" o/ Qiteensfiury
BUILDING and ZONING DEPARTMENT
Bay and Havifand Road, Fi. Ll_ 1 Box 98
Queensbury, New York 12801
BUILDING INSPECTOR ' S REPORT
NAME ::n
ee
LOCATION
or
slj +/�J.f
Date-r0p/_/__jFk Permit Na , I - I ✓
✓ = APPROVED r YES NO
Forting/Pier Forms
Foundation.
Waterproofing
Backfill
)CFraming
Roofing -
Siding
Masonry Vene r
Rough Plumbin
Relief Valves
Ext . Porches
Finished Floors
Interior Trim_
Stairs & Railin
Cellar Drain Ti e
Concrete Floor
Plbg , Fixture
Gar . F'irepro fing
Door Closers
Smoke De t roc rs
Chimney_
INSULA'i'IoN :
Foundation
Floors
Walls
Ceilinr)
FINAL ELECTRICAL INSPECTION
DRIVEWAY APPROVAAL
Final Building Survey
Next scheduled inspection ( cal. l when ready )
Remarks--
13 din Ins ector
6/86 md- V 1
7."n v/ Qt een3h [try
BUILDING and ZONING DEPARTMENT
Bay and Hawiland Road, R.D. 1 Box 98
Queensbury, New York 12801
BUILDING INSPECTOR '
S REPORT
NAME
L0CAT 10N _.W>,l rr
Date' J J .Permit No .
✓ =Footing/Pier Forms APPROVED S NO
Foundation
Waterproofing
Backfill
4wpTaming
Roofing
Siding
Masonry Veneer
C,Uergh Plumbing
Relief Valves
Ext . Porches
Finished Floors
Interior Trim
Stairs & Railings
Cellar Drain Til
Concrete floors
Plbq . Fixtures
Gar . Fireproof ng
210ar Closers
Smoke Detect s
Chimney
INSULATION :
Foundation
Floors
Walls
Ceilinq
FINAL ELE TRICAL INSPECTION
DRIVEWAY A PROVAL
Final Bull ing Survey
hlext scl�eduied inspection ( call when ready )
Remarks-
.
04S k
Bui Spector
G/86 and-VI
0/ Quee" Jlupy
BUILDING and ZONING DEPARTM1AENT
Bay and Haviland Road, R. D. 1 Sox 98
Oueensbury, New York 12801
BUILDING INSPECTOR ' S REPORT
NAME uI`¢�,v'� r�
L d CA T I O N f ,,,,�+ r��'' / 4`5' y o&-A j 14,c-C c _
Date 1,;� Permit No .
✓ APPROVED - YES NO
)(Footing/Pier Forms Loco
X Foundation
)Waterproofing
)(Backfill
F rarni ng'
Siding
Masonry Veneer
Rough Plumb g
Relief Valves
Ext . Parches
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 ELECTRI L INSPECTION
DRIVEWAY APPRb Al.
Final Building Survey
Next scheduled inspection (call when ready )
Remarks- ] OsJ56 J`QCr-rtwL5 t +C3 F-L7 1L
s--
tbnr-; .ems Ct ,xrmvo r6I4r3� � e —
PocfCr/oe
Bui ing In a or
6/86 and-vl
�-f7 2 � l�//� y� ,
BUILDING and ZONING DEPARTMENT
Bay and Haviland Road, R. D. 1 Box 98
Queensbury, New York 12801
BUILDING INSPECTOR ' S REPORT
NAME `
LOCATION 496 f �3L � //S
Date / /� Permit No *
✓ = APPROVED - YES ND
]sooting/Pier Forms
`1&oundation
Waterproofing
13ackfill
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 . Fireprooflnc.
Door Closers
Smoke Detector
Chimney'
INSULATION :
Foundation
Floors
Walls
Ceiling
FINAL Pi CTRICAL INSPECTION
DRIVEWA APPROVAL_
Final 8 ilding, Survey
Next scheduled inspection ( call when ready )
Remarks-/,r r r,al3 D 44 1E4,o a AfoT-1 ca
(Do Al ����. �'r
uilding Ins ctor
6/86 and-vl pro
1
G' BUILDING jand ZONING DEPARTMENT
Bay and Haviland Road, R. Oi_ 1 Box 96
4ueensbury, New York 12801
BUILDING INSPECTOR ' S REPORT
NAME1GCCi
LOCATION fz;7
14�, X� �
Date �f / Permit No .44W
✓ = APPROVED - YES
Doting/Pier Forms
Foundation
Waterproofing
Backfill
framing
Roofing
Siding
Masonry Ven er
Rough Plumb. g
Relief Valve
Ext . Porches
Finished Floor
Interior Trim
Stairs & Railing
Cellar Drain "file
Concrete Floors
Plbg . Fixtures
Gar . Fireproofing
Door Closers
Smoke Detectors
Chimney
INSULATION :
Foundation
Floors
Walls
Ceiling_
FINAL EI ECTR CAL INSPECTION
DRIVEWAY APPROVAL
Final Building, Survey
Next scheduled inspection (call when ready )
Remarks-
Pa
f3u--Tiding = spe or
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,
TEMR_• DATE .' ,' . .,
CITY OR
VILLAGE
STREET AND NO. OR TOWNSHIPCtK �.`j fi' J � COUNTY
ROAD AND POLE No. "3 �
BETWEEN yW;AT TWO PQIE Np.
CROSS STREETS IS
PREMISES LOCATED'+ (& SECTION ^`
OCCUPANT'S BLOCK LOT
NAME BUILDING
OWNER'S NAME �,y yam' OCCUPANCY .. .," ... .... f"'� ..
AND ADDRESS f - J I� Y�'"1"' ( {J y�,, (3 l"�„-jam ..y �`f f",•-" TEL.cuwnl
BSY�PPl IEd /V,* jlw - ♦ % d%0f/T LnC✓/ry FROM
OM THEIR (,fir,[„ '�,w{/j �r. �/'�
BUILDING OFFICE�-TL����,,.,
IS NEW i.p OLD Q WpRK DEFECTS IS NEW L`J^'" ADDITIONAL REMOVED 4_I
LIST BELOW ALL EQUIPMENT
.WHICH YOU INSTALLED �—
NUMBER OF OUTLETS No. rA Fia= a BRANCH
Leer t-emP Rawptrelel MOTORS HEATERS CIRCUITS OFFICE USE
Ben ONLY
GNkyt WAN R M pp'ks Svdtdt PteMAel Breaket No. Typa H'P' we A.W.O.
Each No. each Ire- dauaa INSPECTION
OlR-
ama
Sub-
beat
Blr
"me
ter FI.
2nd Fl.
aid FL
REMARKS: LIST OTHER ELECTRICAL DEVICES NOT S£T FORTH ABOVE: "
OO NOT USE THIS SPACE"
This applicatkeM j,S jntAndad Ie cover the abo m-fisted equipment to be 6rw4 a tad but jl at time of i you are authorized to maka d.e irapectjon and adlust tha fee to&Dyer the additional neon them is found adki�tianAl aquwom t not above fisted.
.quipmrM, es Provided isy the applieenl.
SIZE OF MAINS ELECTRIC SIGN y�e".i� �f-2�^j?,]� FEEDERS LAMPS WATTS TOTAL
CHARACTER OF WORK EXPOSED GAS TUBE SIGN
CONCEALED TRANSFORhIERS OF
WORK TO BE VA
STARTED COMPLETED )NUMBER) ;CAPACITY)
S12£ OF SIGN
SERVICE OVERHEAD UNDERGROUND y,ENTERS I LD ^4 MAKER
IN OF SIGN
INSPECTION REOUESTEO
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