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1989-054 IT If loom 'rw ERrnfICA .iti. a..++ (.3j"Un CU L AN(.rlf ` TOWN OF QUEENSBURY WARREN COUNTY, NEW YORK I Date April7. - 19 cf:�:;�flt 14 � .� This is to certify that work requested to be done as shown by Permit No . i has been completed, I , tr 4t 1 1 Y This structure may be occupied as a Location {t ' "A0f I By Order Town Board TOWN OF QUEENSSURY 1 Director of Bldg. & Code Enforcement f BUILDING PERMIT TOWN OF QUEENSBURY P3 No. 89 - 54 ' WARREN COUNTY. NEW YORIK �s 0 co PERMISSION is hereby granted to W i 11 i am I7 s L s i a n a lj I OWNER of property located at N43 (fireet, Road or Ave. I� in the Town of Queensbury, To Construct or place a s i n g l e Fami 7 )' Dwelling 1 1 at the above location in accordance to application together with plot plans and other information hereto filed andLM approved and in compliance with the Town of Queensbury Building and Zoning Ordinance. t. OWNER'S Address is 7 Butternut Bill Road to Glens Falls , N . Y . 12801 t� to 2. CONTRACTOR or BUI LDE R'S Name to P . J . enterprises ToJo Builders ` I--t- 3. CONTRACTOR or BUILDER 'S Address F" XXX1§XXWN9dXj&XXMXX 37 Briwood Circle 38 Dix Avenue EXt . Glens Falls , N . Y . 12801 Pi Glens Falls , N . Y . 12801 4- ARCHITECT'S Name --1 t7J S. ARCHITECT'S Address s� (D r'S 6- TYPE of Construction — (Please indicate by XI r1' i ) Wood Frame { ) Masonry l ? Steel M N lJ 7. PLANS and Specifications No. 24 ' x 421 single family dwelling as per plot plan , o w specifications , and application . Including septic and 8- Proposed Use a-77tached One car . Single Family XXX Dwelling r u� 25 . 00 c/o $ / �j PERMIT FEE PAID -- THIS PERMIT EXPIRES SerFtember 79 89 {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.} r Dated at the Town of Queensbury this _ ? 'A x^ Day Y of February SIGNED BY Gf (�Sei' �?L � for the Town of Queensbury � Building andZoning Inspector AXIC H N Qq T!J] WN OF QUEENSB URY APP I. I CATTON FOR BUILDING AND ZONING PERMIT 1' tc RECEIVED �`e aieu er•Ily- Reviewed FF B 14 1989 .r Fee Paid �/- c" �- BLDG, & CODE DEFT. BUILDING AND CODES DI YAI:TPIENIi' Date Ibeued BAY and HAVILANA RQA.D_5 RU I Dox 9d OUEENSBURY, AIEW YOIRd: 1 .1804 Pe.AL iZt No . ficI . ( 528) 792-5832 Ext 204 # rt rt • • # ■ Ir r # rF yr a a # w # # # 7r w # se # �4 # ,t # r # w • # # R # A I'I_RMT MUST Li}) OBTAINED BEFORE LI: CINPIINC CLINSTRUC:TIONa NO INSPECTIONS WILL BE MADE UNTIL APPLICAP!T HAS RECEIVED A VALTI3 BVILDINC PERMIT . All applicable spaces on this application must be completed and the &0punture of the applicant must appear on tlic reverse side of this sheeto The owner of this property is : L' . O . Address J G TEL . / Property location G f 'TAX MAP NO . ttas there been any split of th s property since October 1 , 1988 ? if yes , Planning Board Review is necessary . yes no SUBDIVISION NAME , IP APPLTC'AnLE � LOT NO . 11117c person responsible for supervision of work as regards Building Codas is : NRMLn / P . G . ADDRESS_1 /r f , / ., 3 TEL .. N04 [tame of builder r i �✓� r, : tess // ir = J/_//f Tel LJ ,nu� of PlurnLa� r / y' N.'.ItRC of tl.ason Tel %/i� `."' - / 14ATURE OF PROPOSLO 4. RK : ZONING IM1 bima&.TION ( ort.ice use only ) root; ruction& of a r[ ow building } ZONING D2SICNATION OF PROPERTY �Ad" ition to a buil4ing PERMITTED PRINCIPAL PERMITTED ACCESSORY Altur,:.ation CO .A 1juilding _._ ( + [o Chang[: to *:xt �: r i.3r d irnen:: ion:;) REVIEW REQUIRED - PLANNING BOARD ZONING UOARD� +Och4r work (ao:cril.7.! ) ' SITE PLAN REVIEW U APPROVED DATE CROSS ARVA OL` PICOPO SCO, "L' f( LICTURL * VARIANCE #{ APPROVED DATE ` lest Ploor / !..7 r sq ft . Remarks • 2 n d Floor sq f t . w C01%jL, T Ll'S'Li l hlf'L]1:rM'i`1ON lxi r rlJ iixiiD UCL.aUW . other i' loors sq Ft . * = ir'= of PZOIIA :rty / � S ft K ft . s not cellar Qr basern4: nC1 LGxis tirrg builalii 1C TOTAL FLOOR AREA ,sci f t . ' Lix3.:: Ging oui1ai.nq 6; U=.e wix. of now st ructur.: eft X L Lyt ` f oLws ation -pierJ ::lab/crawl/parti.Al/ full " rrcoposcd builaLnq , dl:acunce from proljurcy iirt►: (circle one } W front yard'^ 3� f t Rear yur-d S f t Na . of stories (krab1c;AblQ *Xpace ) �, „ � rt� ighc ( Uradc to ridq.4 ) WWWWWW ft . ,� Sides yards � cc and c It' re :: idcntial , no , Of f:arnilia::.; If on CGrna:r , ;;L• tb:awk .CYflrl[ side :: tr�r:t e �L' C No * of rootns ( excludinq b;Ath:x ) OCCUPANCY INFOP44ATICN tLoa of budroo[r}i: WWWWW # PRIMARY LrUILD114C - No , of t�:ackiraou[:: j --• . ,. X Otte Lastrily dwelling :a Priw4:Ary huting L:YsLv[n / is a it . M --•--a- Two faurily dwulli».} 'i'ypaa u f f ua31 Nu , of firiialacc:: Cr. Lu ir►st:.114ci • multiple alwc:lling / Number of units Will a wuu.i :�tovu l,u i[ [:; t:allual? r La_rrn.►rl[ rLt oCa7upar,cy LL:ntr:al Air carwiitiran i r[y ? . 'L'r:an�ia:rat u[ cufrur[c y � Uusi.nc:sa BUILDING STYLC, PR I KkRY STRUCTuRL= inckuscr ial cabin Ocha:r t:.ai�uQ r:ar7Ctt M.rnai.c+�t DuL,lux * IC ;Addition , ♦ 1b"C will uu+;: buY :.lL31 .1. 0 1uV+:1 014 atyla Uul �".I... low # r.'.:.Vdj Cod CoLt:. Qo OLALu r { ACCESSORY C3UILL]IWC - CK icrni:il lcflw TOWIN 11ou.e ' 1►utaeha ci Ua4c2ayG/one car/ two car/ c"r ( CIRCL.L: ONE: PLEASE 7 " ,L Actached rjararj or3.: car- we car/� cu •' # a * # # # 9a a w w . a x # # ■ LaY1V:a t+= storage fll.1 x a i nr•J L: ;TIMATIi n MAkKr*1% VALUE! OV ' ^^Ozhc= r Corr :; 1rktjc•r 10 wq, maw ] NPORmATTON ON OUTLOTNC spcer ' TCATIONS , ON REVERSE SIDE: OF TITS CHVE"P, TO 02 COMPL.L•:'I'EDI Form DPA 10188 v1 BUILDING PERMIT APPLICATION CONTINUED BUILDING SPECIFICATIONS : , 2 Type of construction , wood frame , fire safe , etc . Will any second-hand or ungraded lumber be used.? if so , for what7l fE t7 Foundation wall material ;�'nt _ .^ r'� f_ (.-�.��. ,£'�r�, 2L Thickness Depth of foundation below grade (to bottom of footing ) , ` Will there be a cellar? Heated or unheated? i loor sq. footage sq ft Will there be a basement? yam- Will any portion be used as living space? /2 r ( If so , what portion? sq . ft . - pe f use? Type of roof - sloped/flat/shed/other �' "< /_ Material of roof Size , wood studs_ "X l spacing "o . c , length L � ft . Joists ( floor beams ) 1st . floor T "X��" spacing Z ; "o . c . span i ft . Joists ( floor beams ) 2nd . floor "' X it spacing "o . c . span ft . Overlays (ceiling beams ) "X spacing "'o . c . span ft . Roof rafters _ " X_ spacin �1 o . c . span� ft . Roof trusses (pre-engineered) spat ` ng . -? ' o . c . spa n�,;�_y/ ft . Exterior wall finish of what material? Interior wall finish If a garage is to be attached , describe mater als to be used for IRE SEPARAT ON : J,,,�L`� a � � ..3r..� ✓` CI �,,. ,=1-J `_t..' {''-' ,._..sue ..--.-' Is there to be an opening between garage and dwelling? i ' If so w ' ~1 a Fi e-rate door , enclosure , and self-closing device be provided? Will a flue-lined chimney be installed? '-} Height above roof ft . Depth of chimney foundation below grade ft . Depth of fireplace hearth ft . in . Water supply - Municipal or private well r ' r SEPTIC SYSTEM _ Distance from ANY private well { including ad ' bining properties_ ft . (A separate application is necessary for any repair or new installation of septic system) D E C L A R A T I O N 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, SignatureG Owner, owner's agent, ar�,PMteibt, contractor SPECIAL CONDITIONS OF THE PERMIT : Hya!� .e'1=..GG TOWN OF QUEENSBURY TC3WIV OF QUEEIVSI3URY WARREN COUNTY , NEW YORK RECEIVED Application for : BUILDING PERMIT IN COMPLIANCE WITH THE NE1rrVjQ�j 1 1(�$(3 STATE ENERGY CONSERVATION CODE 11 D7L A permit must be obtained before beginBLOM, I&OGbDE DEPT, ANSWER ALL of the following : 1 , Gross floor area . � 2 . Type of heat. 3 . Is the building mechanically cooled ? y / 4 . Percentage of area of windows and doors __ lt.�• � ' A . Over 16 % Only 1 . Uo 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 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 50 Type of insulation BO Under 16 % Only 1 . R value of roof and ,floor' s—exposed to ambient conditions . 1 91 l 2 , R value of exterior walls - , S 3 , R value of glazed areal ' _ 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 8 , R value of heated basement/ cellar walls ( above grade ) 90 R value of heated basement/cellar walls ( below grade ) 10 , Type of insulation. � C� - C , Controls 1 . Thermostat maximum heat setting D , Duct Systems 10 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 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 , f ( ppI tpofi is signature ) TOWN 4F QUEENSBURY APPLICATION FOR TOWN OF QUEENSBURY � ---- � RECEIVED �} SEPTIC DISPOSAL PERMIT FFB 1, 4 1989 DATE J ./j�1524= BLDG, & CODE DEPT. LOCATION OF PROPERTY FOR INSTALLATION 1 Owner ' s Name : Y f Telephone : 01 - Address : Z Z&..00.4: ut�40e Installer ' s Name : i'l/ f� /" Telephone : Number of bedrooms (residential only ) �3 Total daily flow ( compute @ 150 gal per bedroom) Topography : circle one : Flat Rolling Steep slope of slope Soil Nature : circle one : Sand Loam Clair Other j Depth : feet Ground Water : At what depth? — feet Bedrock or Impervious Material : At what depth? — feet Percolation test : circle one : n re quired -not req red required /rate min inch . Domestic water supply : circle one : unlcipal, Well Other I £ domestic water supply is a Well : Separation : Watersupply from Septic absorption feet PROPOSED SYSTEM : Septic Tank QC7 gal . (minimum size : 1 , 000 gal . ) TILE FIELD : Each Trench "feet / Total system length Ab Peet SEEPAGE PIT ( S ) : Number of / Size each feet by feet Size of stone to be used #6 /Depth or Thickness feet 9r iF�c ak is aF at ak ic#+c Yc�k*9c is do yr�c dr do it*ir k i�fk*�t 9r ik�4*ic�k is ik ik yt it*ir ik i�ic 7r*****�k at is I have read the regulation on the reverse side of this sheet and agree to abide by these and all requirements of the Town of +Queensbuvy Sanitary Sewage Disposal Ordinance . Signature of responsible person : doe Date • (OVER) 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 installa- tion , alteration or repair of an approved system , a new proposal must be submitted to the Queensbury Building Department before further construction . Town of Queensbury BUILDING and COEWS DEPARTMENT Bay and Haviland Roads Queensbury , New York 12804 Remarks : ,� }` /n''.N It'd✓ /"""f`'`/�' ' .�`.` e y • i BrsxaGway Stela Office Building State Office Building State Office Building MonanOs Hawley Street ISO Livingston Street 125 Main Street 175 Fulton AMenue 155 Main $/rest W. East Washington St. At.BANY 1224 BINGHAMTON 13901 BROOKLYN 11248 BUFFALO 14203 HEMPSTEAD 11SW ROCHESTER 14614 SYRACUSE 13202 a STATE pF NEW YORK WORKERS COMPENSATION BOARD THIS AGENCY EMPLOYS AND SERVES THE HANDICAPPED - WITHOUT DISCRIMINATION, OFFICE AT: rc L810 BA CSHARIRMOM NON STATEMENT THAT APPLICANT DOES NOT REQUIRE WORKERS ' COMPENSATION OR DISABILITY BENEFITS COVERAGE (Ref : Sec . 57 , WC Law ; Sec . 220 , Subd . 8 , DB Law) Applicant ' s Name CA, / E . R . No . Address ' 0 X '' 'cam fry C.Ioo c / l c� /]�1J Vic Office At Business or Trade Name , if Different From Above The above named applicant for permit subject to restriction under Section 57 of the Workers ' Compensation Law , and Section 220 , Subd . 8 , of the Disability Benefits Law , makes the following statement for the purpose of establishing that he/ she does not require coverage under these laws . 1 . Location of work 2 . Exact work to be performed 3 . Number of workers— 0 u ' 4 . Date work is to be (a ) commenced gI14 /?'�? (b ) completed/,Jc� Tw,7`i l [] I have workers ' compensation insurance ( certificate attached) . �rI do not need workers ' compensation insurance because status is Individual owner or partner with no employees and not a corporation . © I do not need workers ' compensation insurance because : © I have disability benefits insurance ( certificate attached ) . / I do not need disability benefits insurance because status is Individual owner or partner with no employees and not a corporation . © I do not need disability benefits insurance because : I hereby affirm , under the penalties of perjury , that I am the above named applicant for permit subject to restriction under Section 57 of the Workers ' Compensation Law and Section 220 , Subd . 8 , of the Disability Benefits Law and that the foregoing statements are /true , Date Signed rL' r�-.G- 19 a z Signature of Applicant Telephone No . .:E2 e— e? +� � S Title 'e==:2 - TO STATE OR MUNICIPAL DEPARTMENT , BOARD , COMMISSION OR OFFICE REQUIRING CERTIFICATE OF WORKERS ' COMPENSATION INSURANCE UNDER SECTION 57 OF THE WORKERS ' COMPENSATION LAW AND UNDER SECTION 220 , SUED . 8 , OF THE DISABILITY BENEFITS LAW Based on the foregoing statements made by the above applicant : The Board has no objections , at this time , to the issuance of the permit requested . p The applicant will be required to have a Disability Benefits insurance policy effective not later than four ( 4 ) weeks after the employment of one or more employees on each of aL least 30 days in any calendar year . It is to be understood , however , that the Board reserves the right to request revo�a- t1on of the permit if , after investigation , it is found that the applicant is required to have workers ' compensation and /or disability benefits coverage for the work referred to in the above application . ,,!! i�i�QRKERS) 6Ak PASPyTION BOARD .�. �Date : 116Z V F V � '.1= .a ./'l.`J. t l� 1 i�:lr*•yfJ�n. 1. .'�•`.._ LT (District Administrator or Supervisor of W . C . Enforcement ) C-105 . 2l (2-88) �CLCC. r oVwlrrYtSS rvnmJ 1Yf,�/ a-vd-:IG V.] r APPLICATION FOR ELECTRICAL INSPECTION - - - - PLEASE BEAR DOWN YOU ARE MAKING (4) COPIES - - - I MIDDLE DEPARTMENT INSPECTION AGENCY, INC. National Headquarters ' 900 Haddon Ave., Collingswood, N.J. 08108 COMPLETESAPPLICANT s D ate r City, Town or Township ;P f-�L�r�''fy. �' / County %'`~ 7�"i ' State f !" Y Location/Address y _ Located " Rural Area - Please Attach Directions] pole yIr Owner. Ar � r � Permit # Occupied As Buiiding: NeWE. l Old m Occupant Work Area in Building Floor #, etc_ ) : App. for: Wiring F�!ff Service -' or: Ready for inspection : Fee Remitted - $ Cash [] Check M.O. [::] Make Payable To. M.D. I .A. Number of Rough Wiring Outlets Elect. Heat 1 500 ]50 1000 125a 1500 1750 200a 2250 2*00 2756 3000 Switches Amp. Service Surface Unit x~ Dishwasher Range Lighting �k' Dryer Pump Receptacles Water Neater Air Conditioner Number of Fixtures Owen Garbage Disposal Wiring and Controls for Burner Amp. Receptacles Fractional H.P. Vent Fans Other Equipment. MOTORS H-P. 1/2 l/12 1/10 1/e 1 116 1 1/4 1 1/3 1 IL 3/4 1 111z 2 3 s 71lz 1 10 15 1 20 25 34 1 40 50 75 100 Mark Number of Each Size AppYicanis _�..+''' Signature `~���F-""`•- ""'� License 4# P It # T/A Utility : . (OFFI L CATION Applicant's ldress / ( A (City)_ + ' !State} "e� = (,zip) _.r:`�i'� Service Reque # Phone # — Electrician : MDIA USE ONLY GATE RECEIVED: DATE INSPECTED: Correct Location : Same as Above [] or : Red Notice Label Rough Wiring Outlets Surface Unit Oven Switches Range Garbage Disposal Receptacles Water Heater Dishwasher Fixtures Air Conditioner Dryer Amp. Service Equipment Burner, Wiring & Controls for Amp. Receptacle Amp, Service Conductors Pump 11 Vent Fans MOTORS H.P_ 1/20 1/12 1/10 1/8 1/6 111411/31 1/2 3/4 1 14x 2 3 5 75lx 10 15 20 35 34 40 50 75 i I 1170 Mark Number of Each Size 1 L t. Heat ___two 1 750 1000 12sa J lsaa lzso zaoo xxso zsoa zzso 3aoo iv ;., Patric& D shrtaw CERTIFICATIONS � USE FOR INITIAL VISIT ONLY NOTIFIED DATE CORRECT FEE PAID Rw Progress: Inc. 0 LKD Contractor 0 CFT Violation : Work Comp, I] Inc. CASH 0 L/A Owner Fee CFiK #p [] L/A Due MO # [� IPA Municipal INV # Date : Other Side Utility Applicant Owner Cut in Card Q Temp # Date I-1 Final # INSPECTORS SIGNATURE Certificate of insurance The Nationwide Insurance Company indicated below certifies that the insurance afforded by the policy or policies numbered and ` described below is in force as of the effective date of this certificate. This Certificate of Insurance does not amend, extend, or otherwise alter the Terms and Conditions of Insurance coverage contained in any policy or policies numbered and described below. Certificate Holder's Name and Address- rnwred's Name and address- r3omn. a,4 QcceetL"u ;d4 "I datAony A. goluL&on ► dzy Road L7/8, 04 Jo qo &ZLde,A& QUeOn burur Ny /2804 37 BrtiUV0d CZAC-Ze // CIESCRiP�VE SCHEDULE POLICY NUMBER AND POLICY POLICY TYPE OF INSURANCE EFFECTIVE EXPIRATION LIMITS OF LIABILITY t$$UING COMPANT DATE DATE GENERAL LIABILITY $6 T?! 3985-LIfJl7I 2f/?/89 2117190 General 3 , 000� Premises - Operations Pr_ Comp_ Op, Agg. - � Products - Completed Operations Each Occurrence /00.r 000 ® Personal and Advertising Injury Any One Person or Organization yjpJ 00U0 ® Medical Expense Any One Person 5�r 000 ® Fire Damage Legal Any One Fire 50,v 000 ❑ Other Liability AUTOMOBILE LIABILITY" Bodily Injury OCCURRENCE IR Comprehensive Form 66 BR 39ttSi'_j-0002 2117189 2117190 (Each Person) ® Owned Bodily Injury (Each Accident) ❑ Hired Property Damage ❑ Non-Owned Bodily Injury and Property Damage /00r 000 Combined EXCESS LIABILITY Bodily Inrtyjury and Occ _ .❑ Umbrella Form CombenedDamage Agg ® Workers' Compensation 66 I've 398 —GIDGY3 21171009 2117190 STATUTORY LIMITS and Bodily Injury ach Accident 6y Accident /00r 0015 W Employers' Liability 646 D& 3985 3/ Bodily injury Policy Limit by Disease $La0 Ow Bodily Injury Each Employee by Disease /00 Insurance in force anly for hazards Indicated by X. Description of Operations / Locations / �/ � {, onrne�te WOAA Vehicles / Restrictions / Special Items NATIONWIDE MUTUAL INSURANCE COMPANY NATIONWIDE MUTUAL FIRE INSURANCE COMPANY NATIONWIDE PROPERTY AND CASUALTY INSURANCE COMPANY I Columbus, Ohio r � Date Certificate Issued f Secre x� President Gas. 3253- 1 -BE Counrtersiyned ot: authorized Representative ISSUE DATE (MF.AICf7 L11,VpYp) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS Son U _M�o.& ,�f J,t.�, - P40 RIGHTS UPON THE CERTIFICATE HOLDER_ THIS CERTIFICATE DOES NOT AMEND, I� I�� E'!'1 CQTT t . EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. i'C74BoCx 2001 COMPANIES AFFORDING COVERAGE ,/.Gems_ Ycr.. L2-,, New llo etk 12801 COMPALETTER A Natwnra.i.de I'1ku eLLa.L .9n& Ca. COMPANY INSURED ��,,��ii LETTER D .q. 6n..�e1jpjT,c�s_P_.C},. 0,4 // d4an. JCL.C..4; 4, ..WYC. CCOMPARNY C 38 d ix. I4v e. COMPAN y;I,ena JI ■l1, New Yakk 12801 LETTER D COMPANY E LETTER ■ t THIS IS TO CERTIFY THAT POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUEDTO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REGUIREM£NT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TEAMS, EXCLUSIONS, AND CON01- TIONS OF SUCH POLICIES. C© TYPE OF INSURANCE POLICY NUMBER DATE WDDPNE POLICY MMMDI Y) LIABILITY LIMITS IN THOUSANDS LTR RATE IMMlDDI'YY'Y DATE {MM,ZiIplYY'I EACH AGGREGATE OCCURRENCE GENERAL LIABILITY ��y BODILY COMPREHENSIVE FORM 66� f'!L 523959(�0o4 .3 /2{�188 03128189 IN-1URY $ $ PREMISESIOIPERATIONS -'' 7J/ f / PROPERTY UNDERGROUND DAMAGE $ $ EXPLOSION % COLLAPSE HAZARD PROOUCTSICOMPLETED OPERATIONS CONTRACTUAL COMBINED $ 5009 $ , 000� INDEPENDENT CONTRACTORS BROAD FORM PROPERTY DAMAGE PERSONAL INJURY PERSONAL INJURY $ AUTOMOBILE LIABILITY bomy �7 rr7 iFirJR✓ + ANY AUTO 66 all 82.J3 95 oI�o 0312[ 188 3128 /� IPry PEFMOri $ ALL OVINED AUTOS (PRIV. PASS.) OMLY ALL OWNED AUTOS 1 P4tlV RPMS / i RPF INJURY $ HIRED AUTOS PROPERTY NON-OWNED AUTOS DAMAGE $ GARAGE LIABILITY BI 3 Piz COMBINED $ EXCESS LIABRFTV UMBRELLA FORM COMBINED $ OTHER THAN UMBRELLA FORM p� STATUTORY f1 WORKERS' COMPENSATION GG W 823 959 00t.72 03128188 (' ,�8,/� 'VZ �, (EACH ACCIDENT) . . AND cC $ (DISEASE-POLICY LIMIT) EMPLOYERS' LIABILITY $ (DISEASE-EACH EMPLOYEE) r? ¢T 105.t 0f1 aaiLdalt % , AA 6 1 823 9S9 004 0,3128189Rogeu& 5t,rcee.;e _ I Jaf.1'._& NY DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLESISPECIAL ITEMS 07129188 14 i/iA So �Zerb& Y Z..a, NZ' rFEW ormariamins li! I 1 (rj + � Cj.L�„ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EX- W.l..c-C- „rf PIRAT QN DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO �//_ 7 �� #� it zU Road MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE II /1 1 � p LEFT, BUT FAILURE TO MAIL SUCH NOTI E SHALL IMPOSE NO OBLIGATION OR LIABILITY yZeIL2 YCl.L.�f_.�o, New -`I'o i� 12 0-1 _ O�F ANY KIN P_ON THE COMPA _ S N*'F�.QR REPRESENTATIVES. AUTHORIZE EP' ENTAT IV E ., mm'( .?. - . . . ..S '7W . ',"# .. :< `e .i •..,".ci.I �.n�,1 i{mow-�3I k ,L f -.. .. c .r-;.qa i' . .:: R;q^.r~�.. 'c. °i$•.�k'r ,"�...:a. ..V."'r m�.. xi.ir .;r. ... ..a'a.^.— 5-r- .. .. « ....:.. k.c��' ^,.,:✓.k.r .. r} _. .. I , CERTIFICATE OF INSURANCE i55LE DATE iFd!d:UFi'}'A'I I PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER- THIS CERTIFICATE HOES NOT AMEND, {t;J4 EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW j COMPANIES AFFORDING COVERAGE e / / �1 COMPANY } CODE `. .0 P1TQ� real/4„, Ii' SU9�! LETTER 'A ,r�'a1'?'TA,l^J' A4EAT Iylt..E�J1 FiR�tJ.�C'ETTI.'C.P_ �G'�71f�'}[I. a€ COMPANY IS INSURED` LETTER COMPANY LE LETTER �. T ,!-Qfj�- s[!.{...L �i1 7�.+J'� ■ wr:'Y)[.7I COMPANY I) LETTER i COMPANY E LETTER COVERAGES tI I IS TO 0f-RT IFY 1-1 IAT T}IF POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INtitCATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WhiIC1-1 THIS CFFiTIFI!;ATF n",AY R,= I:SCI IFn r7R nnnv 1'FR TAI N, THE INSURANCE AFT-ORnrD RY TI-Ir POLKf lF.q nFgCRIRFn HrREIN IS SURJFCT T!) .At.[- TIHF TFRNIC, I EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE LALEN HEDUCFD BY PAID CLAIMS. i f CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LTR DATE (MMIDDIYY) DATE (MM;DtNYY) ALL LIMITS IN THOUSANDS GENERAL LIABILITY GENERAL AGGREGATE S f f (wf ' X COMF.IF,RCIAL GENERAL LIABILI tY PRODUCTS-COMPIOPS AGGREGATE 9 CLAIM$ MADE X OCCUR, ij% f r ryy.� I / w' "`14 i', 9 , ' �L+'S/SJG 1I r J e�` f/ ,� r! 70 PERSONAL 8 ADVERTISING INJURY 5 OWNER'S. 8. CON TRACTOR'S PROT. EACH OCC uiiRENGE S ('M r ;S EiRF DAMAGE (Any nne fire) $ k MEDICAL EXPENSE (Any one person} S MA AUTOMOBILE LIABILITY Sy L'"GO 71 X. ` +'*JS!iFZ':r� ' Ir°f ^['r[-"L/J ' ' SINECOMBINED $ r ' ANY AUTO UMIT ALL OWNED AU I OS BODILY SCHEDULED AUTOS INJURY S (Per person) 1'4IRED AUTOS BODILY p NONOWNED AUTOS INJURY S(POr OGGidenl) f GARAGE LIABILITY PROPERTY $ k DAMAGE EXCESS LIABILITY' EACH AGGREGATE ! OCCURRENCE k $ U THFR THAN 'UMURELL.A FORM i I WORKER'S COMPENSATION STATUTORY ,�'/^ [a ,/�/y /'�,� AND ii[}+�F � ..ryr y rr /: $ ofk/o.0 S�+yLyR.`yr (EACH ACCIDENT) EMPLOYERS' LIABILITY $ '�FJV/p V^L�{„/ (DISEASE—POLICY LIMIT) S /(0} tre" (DISEASE—EACH EMPLOYEE OTHER fri i'fCrO .�oR� ,� ar'Q,rB (7,/ yry l I I r DESCRIPTION Or 0PERAT IONSILOCATIONS7VEH I CLESIR EST RICTIONSJS PE CIA L ITEMS ` CERTIFICATE HOLDER CANCELLATION j YY {.L.r;.rf,am De.4.IazezzA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE 1 EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO Q(;'1f. PJl.►71'G';�' rT « MAIL - „any! DAYS WRITTEN NOTICE. TO T LIE CERTIFICATE- HOLDER NAMED TO THE j _� ,Zpn = Yatt / NY 12801 LEFT" BUT FAILURE TO MAIL SUCH NOTICE 'SHALL IMPOSE NO OBLIGATION 01F; 11 LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACOTM 25-S IzlB£il ACORD CORPORA 19R$ TOWN OF QUEENSBURY BUILDING AND CODE'S DEPARTMENT BAY & HAVILAND ROADS QUEENSBURY, NEW YORK 12802— TELEPHONE (518) 792-5832 .1------ BUILDING INSPECTOR ' S REPORT REQUEST FOR TNSPECTSON RECEIVED NAME aGx7 LOCATION DATE R ERMIT # c APPROVED YES NO FOOTING/PIERS MONDLITHTC POUR FORMS_ FOUNDATION/DAMP—PROOFING BACKFILL APPROVAL" ROUGH PLUMBING FRAMING ELECTRICAL R GH—IN INSULATION: FOUNDATION / FLOORS WALLS CEILING V,;:XXAL INSPECTTON: CHIMNEY HEIGHT ROOFING fr SIDING EXTERNAL PORCHES/STEP STAIRS—CLEARANCE & RAT PLUMBING FIXTURES/REL VALVE INTERIOR TRIMIPRTVAC DOO FINISHED FLOORS GARAGE FTREPROOFIN DOOR CLOSER (S) SMOKE DETECTORS FINAL ELECTRICAL I SP$CTION FINAL APPROVAL OF CONSTRUCTION A SIGNED CERTXPxLATE OF OCCUPANCY MUST BE OBTA1"NED FROM THE BUTLDTNG DEPARTMENT BEFORE THESE PREMISES ARE OCCUPIED.! REMARKS: INSPECTOR BUILDING and ZONING DEPARTMENT }] Bay and Haviland Road, RID . 1 Box 98 Queensbury, New York 12801 SEPTIC DISPOSAL 'SYSTEM INSPECTION .� NAME LCCAT ION DATE / PERMIT NO*� ! SOIL TYPE an Loam - Clay + Percolation Test Required? YES Percolation ate - Min/inch TYPE of SYST ' Absorption fie total leng�h Length of each ench Depth of trenche - Size of grave] SEEPAGE PITS4N of) Size- X ft, Gra size � -------�— P IP ING : size ,Xy e BldgII, to tank Tank to gist. box Dist. box to field] Partial Openings sealed? S O L,OC73TION jSEPARATI t. Foundation to tank: t. Foundation to abs . rption Absorption to 10 line S LOCATION OF SYST ON PROPERTY (ci cle one) Front - Rear ft side Right s e - CC[yMENTS lip SYSTEM USE APPROVEDa(�. NO ns 01j86 and vl TC3iYN OF QUEENSBURY BUILDING AND CODES DEPARTMENT /? � BAY .F HAVILAND ROADS QUEE'NSBURYr NEW YORK 12804. TELEPHONE (538) 792-5832 BU I LD I RIG INSPECTOR ' S REPORT REQUESTS FOR, SNSPECTXON R ECEIVED NAME _/d_ i_ 11 7 T7I y arm LOCATIONt � DATE s L — PERMIT # " APPROVED YES NO FOOTINGIPIERS MONOLITHIC POUR FORMS FOUNDATION/DAMP—PROOFING BACKFILL APPROVAL ROUGH PLUMBING FRAMING EI, 'CTRSCAL ROE GH XN SULATION. FOUNDATION FLOORS 04 .,40 pft WALLS CEILING — • FINAL INSPECTION: CHIMNEY HEIGHT s ROOFING SIDING 1p EXTERNAL Pc?RCHE$/STEPS STAIRS—C'LEARAN E & RAILS PLUMBING FIXTL*RESjRELIEF VALVE INTERIOR T(CAL ' PRIVACY DOORS FINISHED FS GARAGE FIROFING DOOR CLOSE SMOKE DETES FINAL ELECTR INSPECTION FINAL APPROVF CONSTRUCTION A SIGNED CERTIFICATE OF OCCUPANCY MUST BE OBTAINED FROM THE BUILDING DEPARTMENT BEFORE THESE PREMISES ARE OCCUPIED!' REMARKS: IA INSPECTOR TOWN OF QUEENSBURY BUILDING AND CODES DEPARTMENT .BAY & HAVILAND ROADS fff QUEENSBURY, NEW YORK I280k TELEPHONE (518) 792-5832 BUILDING INSPECTOR ' S REPORT REQUEST FOR INSPECTION RECEIVED NAME GAG/ /Y 7i� of LOCATION , DATE APPROVED YES NO FOOTXNG/PIERS MONOLITHIC POUR FORMS FOUNDATTONIDAMP—PROOFING, BA !l,!ILL APPROVAL UGH PLUMBING I• J. AMING I r ELECTRICAL GH—SN INSULATION: FOUNDATION ' FLOORS WALLS CEILING FINAL INSPECTION: CHIMNEY HEIGHT ROOFING ; .SIDING EXTERNAL PORCHES/SEPS STAIRS—CLEARANCE A AILS PLUMBTIVG FIXTUREJIRE�hrEF VALVE INTERIOR TRIM/PT{++IVACYee DOORS FIIVISHED IREPR FLOOR GARAGE F FING DOOR CLOSER (SJ SMOKE DETECTO S FINAL ELECTRIC INSPECTION FINAL APPROVAL OP CONSTRUCTION A SSGNED CERT ICATE OF OCCUPANCY MUST 8E OBTAINED FROM HE BUILDING DEPARTMENT BEFORE THESE PREMISES E OCCUPSEDt REMARKS: t INSPE R � 0J TOWN OF QUEENSBURY .BUILDING AND CODES DEPARTMENT BAY & HAVILAND ROADS �+ QUEENSBURY, NEW YORK 12804- TELEPHONE (518) 792-5832 BUILDING INSPECTOR ' S REPORT REQUEST FOR INSPECTION RECEIVED ,�;z - S - gel NAME LOCATION + DATE L�� PERMIT # 9 9- �re APPROVED YES NO VFOOT-rNG/PIERS MONOLITHIC POUR FORMS FOUNDATION/DAMP-PROOFING BACKFILL APPROVAL ROUGH PLUMBING FRAMING ELECTRICAL ROUGH ,IN INSULATION: FOUNDA TION FLOORS WALLS CEILING FINAL INSPECTION: CHIMNEY HEIGHT ROOFING SIDING EXTERNAL PORCHES/STTZ'PS STAIRS-CLEARANCE & RAILS PLUMBING FIXTURES/;RELIEF VAZVE INTERIOR TRIMIPRIPACY DOORS FINISHED FLOORS GARAGE FIREPROOP TNG DOOR CLOSER (S) i SMOKE DETECTOR°�d FINAL ELECTRICAL]T INSPECTION ,� FINAL APPROVAL cif[` CONSTRUCTION A SIGNED CERTIFICATE OF OCCUPANCY MUST BE OBTAINED FROM THE ;BUILDING DEPARTMENT BEFORE THESE PREMISES ARE OCCUPIED!' REMARKS: _J)�, —� INSPECTOR TOWN OF QUEENSBURY .BUILDING AND COZIES DEPARTMENT BAY & HA VILAND ROADS QUEENSBURY, NEW YORIC 12809- TELEPHONE (518) 792-5832 BUILDING INSPECTOR ' S REPORT REQUEST FOR INSPECTION RECEIVED NAME ` LOCATION -06 DATE , / /fd,, PERMIT APPROVED YES NO FOOTING/PIERS MONOLITHIC POUR FORMS �FOUNDATIONfDAMP-PROOFING �/BACKFILL APPROVAL ROUGH PLUMBING FRAMING ELECTRICAL ROUGH-IN INSULA TION: FOUNDATION FLOORS WALLS CEILING FINAL INSPECTION: f .• CHIMNEY HEIGHT ROOFING SIDING EXTERNAL PORCH IST&ps — - STAIRS-CLEARAN E & RAXLS PLUMBING FIX RES/RELIEF VALVE INTERIOR TRI fPRIVACY DOORS FINISHED F RS GARAGE FIR PROOFING DOOR CLos (S) SMOKE DE T C TC7R- FINAL ELECT ICAL INSPECTION FINAL APPROVAL CIF CONSTRUCTION A SIGNED CERTIFICATE OF OCCUPANCY MUST BE OBTAINED FROM THE BUILDING DEPARTMENT BEFORE THESE PREMISES ARE OCCUPIED: REMARKS.: INSPECTOR TOWN OF QUEENSBURY EUXLDXNG AND CODES DEPARTMENT �7 /� SAY & HAVILAND ROADS III 1 .0 CUEENSBURY, NEW YORK 12801 1 TELEPHONE (518) 792-5832 BUILDING INSPECTORIS REPORT REQUEST FOR XNSPECTXON RECEIVED NAME LOCATION T DATE CS J PERMIT APPROVED YES NO XOOTING/PIERS MONOLITHIC PO FORMS FOUNDATIONIDAM PROOFXNG BACKFXLL APPROT, # ROUGH PLUMBING \ FRAMXNG ELECTRICAL ROUGH-XN' INSULATION: FOUNDATION FLOORS WALLS CEILING FXNAL .INSPECTION: CHIMNEY HEIGHT ROOFING SIDING EXTERNAL PORCHESISTEPS STAIRS-4LEARANC & RAILS' PLUMBING FIXTU ESfRELIEF VALVE INTERIOR TRrM RXVACY DOORS FXNXSHED FLOI S GARAGE FXREP OOFXNG DOOR CLOSER ( ) SMOKE DETEC RS FXNAL ELECTR AL INSPECTION FXNAL APPROV L OF CONSTRUCTION A SIGNED CER XFICATE OF OCCUPANCY MUST BE OB'TAXNED FROM THE BUILDXNG DEPARTMENT BEFORE THESE PREMISES ARE OCCUPIED! REMARKS: INSPECTOR / MIDDLE DEPARTMENT INSPECTION AGjENCY, INC. National Headquarters 900 Haddon Ave., Collingswood, N.J. 08108 Date City, Town or Township /?/�/r �, -" County_ �s�./�1�' ✓t State Location/Address f' ;.! y- ' - Located ' Rural Area - Please Attach Directions} Owner /f- 7.f� .� •� r ' s Pale # . Occupied As Permit # 47 Occupant Building: Newts Old © for: Wirin work Area in Buiidin Floor #, etc. ): Service � or- Fee Remitted • $ Read for Ins ection : Cash Check �] M.O. (� T Number of Roulgh Wiring Outlets Elect, H 5o Make Payable o: M.D, I.A. eat soo �5o x000 x2 1500 1750 2aee 2290 2aoa 2s5o soda Switches Lighting `Amp. Service Surface Unit Dishwasher Receptacles — — Water Heater Air Conditioner —­� Dryer Range Number of Fixtures Oven Pump Garbage Disposal Wiring and Controls for Burner Ainjl. Receptacles Fractional ent Other Equipment: H.P.. Fans MOTORS H,P, 1/2 1f12 1110 1/e 1/6 1/4 1/3 lf2 3f4 1 14x 2 Mark Number 3 S 7111 30 15 2D 2S 30 40 50 75 1D0 o111111111 f Each Size APPlicant's Signature T/A License # it A{1PliCant's Address; - tility; A CAT N Phone #� - h —'"" (State) .(ZiP} Service Request # Electrician ell DATE RECEIVED: correct Location : Same as Above IJ or: DATE INSPECTED: Red Notice Label Rough Wiring Outlets Surface Unit Switches Ran Oven Race tacles water Heater Garbage Disposal } , Fixtures Dishwasher Ali er040nditioner ' Amp, Service Equipment Burner, Wiring & Controls for Dryer AmP. Service Conductors Pump Amp. Receptacle M Mark Nur H.P, 1f2D 1f12 1/10 1/8 ife lf4 1/3 1/2 3f4 1 14s 2 Vent Fans Mark Number 3 5 7kz 30 15 2D 25 30 a0 50 75 1DD of Each Sias Elect. Hea# 550 750 xOQD x25O I5OR 1>9U 2040 2250 2a08 2796 30p0 dd RW P grass: Inc, Q 0 CFT LKD [] Contractor Violation : work Comp. Q lnc, 0 L/A ED L/A Owner CASH [] IPA Fee CHK Municipal Due MO ## Date : I N V # Other Side Utility Applicant Q Owner o Cut in Card © Temp # Date: Final # Dam ANSPECTORSSIGNATURE APPLICATION FORM NO. 250 EL 11/a6 APPLIC^AN7"S COPY ro a {� N 6Ul m TOWN OF QUEENSBURY RECEIVED APR 31969 Bl. G. & CODE DEPT. n - .73 � 1. �1 000 0 2 N z Ito .0 4- T T i i _ -2 � � i �-1►'��'� N (,d w� FAQ . ot6rrlz I Sul ljqrj bot. - 4feope, -TAWIC --J c IE L. lz;l llo- w 4 N -2 u) O LE G �N vD4i S 0 0-T. G - IC t4 0 UT To, C2 9. k-Oe� i 4E L Q ;P i N OT'-- r, 1 OWNF-7z C, `i TH R4F-� )915 FT' L\ TOWN OF Q)JE BUILD114'G REVIEWED BY DATE E 'OF Ry ,iPT. '. PLOT PLAN tzo-31 %FIRM TIC MOM AUTINION' FK) 1, BOX 670- Aff%T 00tSTRK PAW, GLENS FALLS, NY I= OW min DE .0.4 *M Q F 0 R.- S THE USE OF THESE PLANS FOR CONSTRUCTION OR ANY OTHER PURPOSE W,T HOUT WRITTEN PERMISSION FROM PROFESSIONAL BUILDING SYSTEMS INC. IS PROHIBITED lrLUMTOM DMAN,99ANCZ.- DO -NOT SCALE THESE DRAWINGS. THEY MAY NOT BE TO EXACT SCALE. USE � NLY THE DIMENSIONS SHOWN. A"By. TO r., FROW DW BY: OWNER AND CONTRACTORS SMALL, CONSULT APPLICABLE BUILDING CODES To INSURE THAT PLANS AND DETAILS CONFORM TO ALL REOUIREMENTS. THEY SHALL VERIFY ALL DIMENSIONS BEFORE MET PROCEEDING WITH CONSTRUCTION WORK AND SHALL NOTIFY PROFESSIONAL BUILDING SYSTEMS DRAFTING DEPARTMENT OF ANY DISCREPANCIES BEFORE WORK IS PERFORMED. Dm: ll--77-88 DATE: PROFESSIONAL BUILDING SYSTEMS SHALL NOT BE RESPONSIBLE FOR ANY AODITIONAL. COST OR STRUCTURAL PROBLEMS RESULTING FROM THE FAILURE TO FOLLOW THESE PLANS AND DETAILS. OF ww"mG No. t,=),g 9 OWERNO. lk,