1989-148 CERTIFICATE 01F OCCI• PANC•Y
TOWN Of QUEENSBURY �
WARREN COUNTY, NEW YORK 1
Date August 16 19 89
vA
� This is to certify that wank requested to be done as shown by Permit No, 89 - 148
I
4 has been completed.
This structure may be occupied as a Fin 1 e Family Dwe 11 i ng
Location
I
Owner Fri F 11 z n h P 1 1FL
i
H}i Order Town Hoard
i
I 1`OWrN OF QUEENSSURY
Director of Bldg. & Code Enforcement
H
BUILDING PERMIT
TOWN OF QUEENSBUR1if'' No $ 9 - 148
WARREN COUNTYr NEW YORK
.c-
PERM ISSION is hereby granted tol, lle Przybylo
1
OWNER of property located at
Street, Road or Ave.
in the Town of Queensbury, To Construct or place a SS i� 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.
�d
1. OVVNE R'S Address. is
N
►C
6 Lydia St . tx
So . Glens Falls , N , Y . 12803 "C
r
0
2. CONTRACTOR or BUILDER'S Name `
Hal Raven �
t:j
3. CONTRACTOR or SUILDER'S Address
58 McCormack Road Q
Lake George , N . Y . 12845
r-i
d_ ARCHITECT'S Name
[TJ
L—'
rl
5. ARCHITECT'S Address
t"
G?
6. TYPE of Construction — (Please indicate by X)
(XXWood Frame ( ) Masonry ( ) Sisal ( )
Cn7
H
7. PLANS and Specifications O
tz
26 ' x ,&2 ' single family dewlling as per plot plan , specifications , m
and application , including septic , attacbed two car gars C:�
to
S. Proposed Use
Single Family Dwelling
25 . 00 C / o ys 8y
$235 OQ PERMIT FEE PAID - THIS PERMIT EXPIRES November 1 H
(If a longer period is required an application for an extension must be made to the Building and Zoning inspector of the �
town of [lueensbury before the expiration date.)
Cr1
Dated at the Town of Queensbury this 1,4.tb Day of April 19$9 —
N
* far the Town of Queensbury
SIGNED BY
$uildirg and Zoning In ctor
G
L=.
t—
t-'
t`
C,
` TO BE COMPLETED BY BLDG . DEFT. 5
C'] f Application No. A TO QUEENSBURY
✓own o areerr36etrt Permit Issued 19 `5 "�T . /0 e) RECEIVED
BUILDING and ZONING DEPARTMENT Permit Expires 0 19 T .�'�
Bay and Ha+uiland Road, R.f7. 1 Box 98 zoning Designat on - f D
Queensbury, New York 12801 Variaunce No. � Sr ��
Site Plan Review No vvU
G. & CODE INEPT.
Approved by :
APPLICATIONFOR (4f
BUILDING AND ZONING PERMIT
A PERMIT MUST BE OBTAINED BEFORE BEGINNING CONSTRUCTION. ANSWER ALL. OF THE FOLLOWING .
The underntgned hereby applies for a Building Permit to do the following work which will
be done in accordance with the description, playas and specifications submitted, and such
special conditions as may be indicated on the Permit ,
The owner of this property is :
P. O. Address / -+ / Tel .
Property Location : -' rem -22 � Tax Map No .�
street number or building lot number 0;jo.
Subdivision name (if applicable)
THE PERSON RE NSIBLE FOR SUPERVISION of WORK AS REGARDS BUILDING CODES ISO
Name P. O. Address Tel No .
Name of builder Tel .
Name of plumber Address Tel *
Name of mason Address Tel .
NATUR F PROPOSED WORK : : ZONING INFORMATION :
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 dissensions) * 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 /+f/ 7-"P>e ft X '�w ft . -f-- %Zt4j R'
Existing buildIng ( s) Size .ft X ft .
PROPOSED BUILDING AND USE ; * Existing buildings ) Use
Size of new structure ft X �'Cft
Foundation_pier/slab/crawl/partial " Proposed building , distance from property line
(circle one ) * Front yard -1 'a d ft Rear yard /. S't "' ft
No . of stories (habitable space) * Side yards ''� Ft and � ft
Height ( grade to ridge ) ft. * If on cornere . setback from side street ,eft
If residential , no . of families /
No . of rooms ( excluding baths ) * OCCUPANCY INFOMMATION
Non of bedrooms S"'
No . of bathrooms —r ", -r< * P� ILDING -
Primary heating s tem �- * e family dwelling
ys * '...Two' family dwelling
Type of fuel G5,pr _ * Multiple dwelling / Number of units
No , of fireplaces to be inatalled.� * Permanent occupancy
Will a wood stove be installed? � 4ep Txansyant occupancy
Central Air conditioning? fZ.:::
* lousiness
BUILDING STYLE, PRIMARY STRUCTURE Industrial
Ranch Contemporary Log cabin * Other
,. If addition, what will use be?
Raised ranch Mansion Duplex
Split level Old style Bungalow
Ca a Cottage Other * ACCESSORY BUILDING-
olonial Row 'Down House * ' Detached garage/one car/ two cars car
( CIRCLE ONE PLEASE ) Eached garage/one car/ car
,r * : * r • t # r * * * + # * * Private storage building
ESTIMATED MARKET VALUE OF * 'Other
CONSTRUCTION
INFORMATION ON BEVWaDING SPECIFICATIONS , ON IUMEI;SE SIDE OF THIS SHEET* TO BE COMPLETEDI
Form BPA 4/86 md--vl
BUILDING PERMIT APPLICATION CONTINUED - +
BUILDING SPECIFICATIONS :
Type of construction , wood frame , fare safe, etc , d '
Will any second-hand or ungraded lumber be used? If so , for what ?
Foundation wall material Thickness
Depth of foundation below grade (to bottom Lt footing )
Will there be a cellar? .Heated or Floor sq* footage s+q ft
Will there be a basem t? 11 any portion be used as living space?
( If so , what porti sq. ft . - - Type of use?
Type of roof - o �/flat/shed/other Material. -of roof
Size , wood stu s :Z is " spacing_ JO_"o . c . lengthft.
Joists ( floor beams ) ist . floor %zw "X /C." " spacing�r�"o . c . span . "" ft .
Joists ( floor beams) 2nd . floor '� "x �.^. '" spacang�"o . c . span e
Overlays ( cealing beams ) "}C •' spacing "o . c . span ft.
Roof rafters la
pacing a . c * span ft *
tpd000�f trusses (pre-engineered) s cingo . c . span 'adtr, ft .
Exterior wall finish L04 . Of what material?
Interior wall finish
If a garage is to be attached , ,descKibe u terials to .-be used for FIRE SEPARATION
Is there to be an opening between garage and dwelling? C, If so will a Fire-rated
door , enclosure , and self-closing device be provided?
Will a flue-lined chimney be installed? Height abolfe roof. �- € t .
Depth of chimney foundation below graded-ft . _ ,.._� `
Depth of fireplace hearth, r� I4::: .n .
Water supply - Municipal or private well
SEPTIC SYSTEM _ Distance from ANY private well { including adjoining properties £t .
(A separate application is necessary forfoTr any repairor new installation of septic system)
Town Of f Warren A F F I D A Y I T STATE OF NEW 'YORK
County of 'Warren
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 __-_--_ i 'RTT.i
er, owner ' s agent , arenitect , contractor
day of 19
Notary Public , warren County , N . Y .
It : * w * w * • w
SPECIAL CONDITIONS OF THE PERMIT :
------------.
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 € ollowin�gt:
1 . Gross floor area ��..�^^ / '�
2 . Type of heaty ,�%`+^Y x-
3 , is the building mechanically cooled ?y
4 . Percentage of area of windows and doors
A . Over 16 % Only
Y . 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
10 If YES , what is the R value ?
3 , Slab on grade YES NO
a . If YES , what is the R value of insulation around
perimeter of floor ?
4 . Is basement heated ? YES NO
a . R value of insulation
5 , Type of insulation
B . Under 1696 Only
1 . R v lure- of of and floors exposed to ambient conditions_
,prf
2 , R value of exterior walls
30 R value of glazed area "' �- y� / /�•
4 , R value of doors ra►� ^»s ++'+ / `�-� " �`�
5 , R value of floors over unheated spaces f
6 , R value of slab edge insulation - unheated slab
7 _ R value of slab insulation - heated slab
80 R value of heated basement / cellar walls ( above grade )
g . R value of heated basement,.'/�-c—e� llar walls ( below grade )
10 , Type of insulation vos^ o"
C , Controls
1 , Thermostat maximum heat setting f --
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
1 . Performance efficiency
2 _ Temperature control setting maximum
G , For Swimming Pool Only
le Maximum heating
Telephone. No , 40"
ture )
( ap licant ` s signa
APPLICATION FOR SEPTIC DISPOSAL PERMIT
HATE
LOCATION OF PROPERTY FOR INSTALLATION
Owner's Name: �`S ^, Ea Z'-Cr!' o elephone:
Address:
Installer's Name: �'r',�'r! .� .•�s� � Telephone:
Number of bedrooms (residential only) —
Total daily flow (compute @ 150 gal per bedroom) �li�
Topography: circle one: la Rolling Steep Slope % of slope _
Soil Nature: circle one and oa Clay
// Other / Depth* feet
Ground Water: At what depth? 4yw4e V0r feet 41 Gvr�
Bedrock. or Impervious Material: At what depth? zllf�2f'� eet Z5:0�0 �
Percolation test: circle one: not required required f rate min. inch.
Domestic water supply: circle one: Municipal el Other _
IF domestic water supply is a Well: / ��I„ �
Separation: Watersupply from Septic absorption _ _ G � feet
PROPOSED SYSTEM: Septic Tank gal. (minimum size: 1 ,000 gal.)
TILE FIELD: Each Trench feet / Total system length feet
SEEPAGE PIT(S): Numbe 1ze eac ee t. . ..
Size of stone to be used #
IMPORTANT
...Please...MST NEW EQUIPMENT TO BE INSTALLED
(over)
Section II 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:
le) 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 dxywells
Be 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.
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.
u:
I have read the regulations above and agree to abide by these and all requirements
of the Town of Queensbury Sanitary Sewage Disposal Ordinance,
Signature of responsible person:
Date: r
Town of Queensbury
Building and Code Department
Bay at llaviland Road
Queensbury, New York 12801
(518) 792-5832
SETTLED 1763 . . . HOME of NATURAL BEAUTY A G*D, PLACE TO LIVE
THE NEW YORK BOARD OF FIRE UNDERWRITERS
BUREAU OF ELECTRICITY
Af STATE STREET, ALBANY„ NEW YORK 12207
Dow 3 ". 1ppticateon 1Vo. one jele Ctg] 8 `
THIS CERTIFIES THAT PER74JI I 'q. 89 1 18
only the eloctricol equiipnaent as described below and introdt e4mi by the—gmi l t m"w ei on t" +dome application ft-u sb er in thepnenalA" of
EF.� u °EYC' li£ i:l_ E. F'R.�,l�Fi7-L:T . kIIIC;E FtU_�Tt . Ck�L�LL'�: ::F3t.'k1- .
in the follawin6 location; Basement La I
let Fl. .r Pnd FT. ' ,� k' Section Block Lot
was examined on I I 'GZ T 1 (--t . 1. r) {' ') anal found to be in compliance with the requirements of this Board.
PIXTUN
RXTURES
rIJIT AGES SWITCHES RANGE HER
S coomNa pRCKS GIVENS DISH WASS EXHAUST FANS TITS NCANDES"Nr PLUgeESCENT OTHER AMT. K. W. AMT, K_ W. ,MAT_ K.W. AMx, C W. AMr, H. P.
�; 3
DRYERS FURNACE !MOTORS R ITWttlE APPLIANCE REOERS SPECIAL REC'fT TIME CLOCKS EEtt WN1T HEATERS MMILTW WTtET �S
AMR. K. w. On H. P. GAs H. P. AMT. No. A. W. G. AMT. AMP. AMT. AMPS. TIRIINS. AMT. H. P. W ff Pam
AMr. WATTlS
NO. Of NtET
I
3 C,iif;l
SEXVWA DISCONNiEF'I no. Of IS E R V I C E
AMT. AMP. TYPE 4VIF Y ,tl' Tw 1 �' 7nv 9 X aW I/ AW NO, GP C. comm aP cc CGomo. rho. oP rH-LEG h W. G. N4.OP "r<i''�'r�c OF NwElmGIAL.
1 Y Pitt 3 Gr HI-IEfi
f 1�1
OTHER APPARATWSc
F' , I�Ik I F. f'
1c7Tttik:: ; 1. F II - F' .
i -J-1E PE i E4CT 3R :
}I ? 3ti:'I I7 EN
7
�, rs k!C`C'ry I('I wcAc r' [: F:Ir .
1- A1;F >FC!kCiF. . *; I ._' t l '
BRANCH MANAGER .
o i ,
Per—
This certificate must not be oitered in any manner+ return to the office of the Board if incorrect. Inspectors may be identified by their credential*.
COPY FOR BUILDING DEPARTMENT. THIS COPY OF CERTIFICATE MUST NOT BE ALTERED IN ANY MANNER.
TOWN OF QUEENSBURY
BUILDING AND CODES DEPARTMENT
BAY & HAVILAND ROADS '
QUEENSBURY, NEW YORK 1280k +'
TELEPHONE (518) 792-5832
BUILDING INSPECTOR ' S REPORT
REQUEST FOR INSPECTION RECEIVED =
NAME _
LOCATION
(�.
DATE ej I�� - PERMIT # S ' J _
APPROVED
YES I NO
FOOTING/PIERS
MONOLITHIC POUR FORMS
FOUNDATION/DAMP-PROOFING d
BACKFILL APPROVAL
ROUGH PLUMBING
FRAMING
ELECTRICAL ROUGH-IN-
INSULATION.
FOUNDATION
FLOORS
WALLS
CEILING
G,�'"FIN.AL INSPECTION: -r
CHIMNEY HEIGHT
ROOFING
SIDING
EXTERNAL PORCHrS/STEPS
STAIRS-CLEARAOCR & RAILS
PLUMBING FIXTURES/RELIEF VALVE
INTERIOR TRIM/PRIVACY DOORS
FINISHED FLOORS
GARAGE FIREPROOFING -
DOOR CLOSER (S)
SMOKE DETECTORS _
FINAL ELECTRICAL INSPECTION
FINAL APPROVAL OF CONSTRUCTION
A SIGNED CERTIFICATE OF OCCUPANCY MUST BE
OBTAINED FROM THE BUILDING DEPARTMENT BEFORE
THESE PREMISES .ARE OCCUPIED!
REMARKS:
INSPECTOR
BUILDING and ZONING DEPARTMENT
Bay and Haviland Road, R. D. 1 Box 9a
Oueensbury, New York 12801
SEPTIC DISPOSAL SYSTEM INSPECTION
NAME
." tLOCATION
0ATE .2Lc� PERMIT NO. Fr
SOIL TYPE - \pand - Loam - clay -
Percolation Test Required? YES' - NO
Percolation rate - Min/Inch
TYPE of SYSTEM:
Absorption field , totaingth_ � 5C7
Length of each #wrench �—
Depth of trenches ,
Size of gVavel
SEEPAGE PITS{Nuigl�er rdf} _ "-
Size- ft. ]f _ ^fft .
Gravel size
oil
PIPING : t Si a Type
Bldg . to tank
Tank to list. x 1
Dist . box to f eld/
Openings seal d? Y NO Partial
LOCATION/SE ARATIONS
Foundatlon to tank k4f t.
Foundatio to absorptioiia t.
Absorpti to lot line ft.
Separat n of pits ---.7�+-ft.
i.00ATI sSTEM ON PROPERTY (circle one)
Front ear Left side - Right side -
CT
S •
, 'EM USE APPROVEAYE NO
l3ne actor
and vl
TOWN OF QUEENSBURY
BUILDING AND CODES DEPARTMENT
BAY & HAVILAND ROADS
QUEENSBURY, NEW YORK 128a4-
TELEPHONE (518) 792-5832
BUILDING INSPECTOR' S REPORT
REQUEST FOR INSPECTION RECEIVED
NAME
LOCATION
DATE / -lrf'Li�Q PERMIT i / t
APPROVED
YES NO
FOOTING/PIERS
MONOLITHIC PO FORMS
FOUNDA TIQN1 -PROOFING
,8� SXFXLL APPRO L
GH PLUMBING
FRAMING
ELECTRICAL ROUGH-
INSULATION:
FOUNDATION
FLOORS
WALLS
CEILING
FINAL INSPECTION:
CHIMNEY HEIGHT
ROOFING
SIDING
EXTERNAL PORCHESlSTE
STAIRS-CLEARANCE & ILS _ ......... ......... .
PLUMBING FIXTURES/ LIEF, V VE
INTERIOR TRIM/PRSV CY DOORS
FINISHED FLOORS
GARAGE FIREPROOF G
DOOR CLOSERS)
SMOKE DETECTORS
FINAL ELECTRICAL NSPECTION
FINAL APPROVAL OF CONSTRUCTION
A SIGNED CERTIFICATE OF OCCUPANCY MUST BE
OBTAINED FROM THE BUILDING DEPARTMENT BEFORE
THESE PREMISES ARE OCCUPIED!
REMARKS.
xN PECTOR
TOWN OF QUEENSBURY
BUILDING AND CODES DEPARTMENT
BAY & HAVII.AND ROADS
QUEENSBURY, NEW YORK I280k
TELEPHONE (5I8) 792-5832
BUILDING INSPECTOR' S REPORT
REQUEST FOR INSPECTION RECEIVED
NAME 42 ,
LOCATION p 7t
DATE '�j f�� PERMIT # 7 14e --
APPROVED
YES INO
FOOTING/PIERS
MONOLITHIC POUR FORMS
FOUNDATION/DAMP-PROOFING
BACI ILL APPROVAL
LAeUGH PLUMBING
FRAMING
ELECTRICAL ROU H-IN
(,,wws'uLATION:
FOUNDATION
FLOORS
WALLS L .
CEILING
FINAL INSPECTION:
CHIMNEY HEIGHT
ROOFING
SIDING
EXTERNAL PORCHES/STEPS
,STAIRS-CLEARANCE & RAI S
PLUMBING FIXTURES/) EL EF VALVE
INTERIOR TRIM/PRIVAC DOORS
FINISHED FLOORS
GARAGE FIREPROOFIN -
DOOR CLOSER (S) -
SMOKE DETECTORS
FINAL ELECTRICAL SPECTION
FINAL APPROVAL OF CONSTRUCTION
A SIGNED CERTIFICATE OF OCCUPANCY MUST BE
OBTAINED FROM THE BUILDING DEPARTMENT BEFORE
THESE PREMISES ARE OCCUPIED!
REMARKS:
NS . _TOR
TOWN OF QUEENSBURY
BUILDING AND CODES DEPARTMENT 1 BAY & HAVILAND ROADS
QUEENSBURY, NEW YORK 12802R
TELEPHONE (518) 792-5832
BUILDING INSPECTOR' S REPORT
REQUEST FOR .INSPECTION RECEIVED
NAME
LOCATION
DATE (G fi PERMIT #
APPROVED
YES NO
FOOTING/PIERS
MONOLITHIC POUR FORMS
FOUNDATTON/DAMP-PROOFING
BACKFILL APPROVAL
ROUGH PLUMB NG
(/FRAMING
ELECTRICAL ROUGH-IN
INSULATION:
FOUNDATION
FLOORS
WALLS
CEILING
FINAL INSPECTION:
CHIMNEY HEIGHT
ROOFING
SIDING 1p
EXTERNAL PORCHES/STEPS
STAIRS-CLEARANCE & RAILS
PLUMBING FIXTURES/RELIEF VALVE
INTERIOR TRIM/PRIVACY DOORS
FIN?SHE'D FLOORS
GARAGE FIREPROOFING
DOOR CLOSER (S)
SMOKE DETECTOR
FINAL ELECTRICAL+ INSPECTION
FINAL APPROVAL PF CONSTRUCTION j
A SIGNED CERT FICATE OF OCCUPANCY MUST BE
OBTAINED FRO THE .BUILDING DEPARTMENT BEFORE
THESE PREMI S ARE OCCUPIEDI
f
REMARKS: At (c& LF
CA-L.L +-in iz. PLvAAi6fNL (,Aj5P61ff7-00-tr
tyltr L � - ( N5 196,CT- rrZ^A r (t/6 /'I-t 13f+T
INSPEC R
TOWN OF QUEENSBURY
BUILDING AND CODES DEPARTMENT
BAY & HA'VSLAND ROADS
QUEENSBURY, NEW YORK I28011
TELEPHONE (5I8) 792-58:32
BUII.I]ING INSPECTOR ' S REPORT
REQUEST" FOR—INSPECTION RECEIVED rA '
NAME Z p
LOCATION
DATE [.j — aG1 I PERMIT #
APPROVED
YES NO
FOOTING/PIER.Sk
MONOLITHIC PO R PORMS
FOUNDATION/D —PROOFING
BACKFILL APPRO AL
ROUGH PLUMBING
FRAMING
ELECTRICAL ROUG IN
INSULATION:
FOUNDATION
FLOORS !
WALLS
CEILING
FINAL INSPECTION:
CHIMNEY HEIGHT
ROOFING
SIDING
EXTERNAL PORCHE (STEP
STAIRS—CLEARANC & RAILS
PLUMBING FIXTU ES/RELIEF LVE
_f
INTERIOR TRIM/ RIVACY De7t7
FINISHED FLOOR
GARAGE FIREPR PING
DOOR CLOSERS)
SMOKE DETECTO S
FINAL ELECTRICA INSPECTION
FINAL APPROVAL F CONSTRUCTION
A SIGNED CERTIFICATE OF OCCUPANCY MUST BE
OBTAINED FROM THE BUILDING DEPARTMENT BEFORE
THESE PREMISES .ARE OCCUPIEDf
REMARKS:
Y4 �k�
INSPECTOR
TOWN OF QUEENSBURY �y' l
BUILDING AND CODES DEPARTMENT 1
BAY & HAVILAND ROADS
QUEENSBURY, NEW YORK 12802-
TELEPHONE (518) 792-5832
BUILDING INSPECTOR ' S REPORT
REQUEST FOR INSPECTI N RECErVED
NAME
LOCATION p
DATE S - - PERMIT ##
APPROVED
YES NO
FOOTINGIPIERS
MONOLITHIC POUR FORMS
L--�FOUNDATIpNfDAMP-PROOFING
G/BACKFTLL A PROVAL
ROUGH PLUM NG
FRAMING r'
ELECTRICAL R GH-IN
INSULATION:
FOUNDATION
FLOORS
WALLS
CEILING
FINAL INSPECTION:
CHIMNEY HEIGHT
ROOFING
SIDING
EXTERNAL PIN
S
STAIRS-CLE LS
PLUMBING FREL F VALVE
INTERIOR TACY RS
FINISHED F
GARAGE FIRGDOOR CLOSE.SMOKE DETEFINAL ELECwPECTIONFINAL APPROVNSTRUCTION
A SIGNED CERTIFICATE OF OCCUPANCY T BE
OBTAINED FROM THE BUILDING DEPARTMENT BEFORE
THESE PREMISES ARE OCCUPIEDI'
REMARKS :
INSPECTOR
TOWN OF QUEENSBURY
BUILDING AND CODES DEPARTMENT
BAY & HAVILAND ROADS
QUEE'NSBURY, NEW YORK 2280!&
TELEPHONE (5I8) 792- 583.2
BUILDING INSPECTOR ' S REPORT
REQUEST FOR INSPECTION RECEIVED
NAME E +Wf rwo. f Z y r3'`( L_c)
LOCATION _Lo-T- q 1-10 Al& t 4l� T- }
DATE `' PERMIT # 9 - l q
APPROVED
YES NO
FOOTING/PIERS
MONOLITHIC POUR FORMS
G poulvDATION DAMP-PROOFING
f`9ACKFILL A PROVAL
ROUGH PLUMB NG
FRAMING
ELECTRICAL R GH-IN
INSULATION:
FOUNDATION
FLOORS
WALLS
CEILING
FINAL'' INSPECTION:
CHIMNEY HEIGHT
ROOFING
SIDING
EXTERNAL PORCHES/ST
.STAIRS-CLEARANCE & RA S
PLUMBING FIXTURES RELI VALVE
INTERIOR TRIM/PR VACY RS
FINISHED FLOORS
GARAGE FIREPR ING
DOOR CLOSERS)
SMOKE DETECTO S
FINAL ELECTRXG JZ INSPECTION_
FINAL APPROVAL] OF CONSTRUCTION
i
r
A SIGNED CERTIFICATE OF OCCUPANCY ST BE
OBTAINED FROM THE .BUILDING DEPARTMENT BEFORE
THESE PREMISE'S ARE OCCUPIED!'
REMARKS:
IN,SPEC OR
TOWN OF QUEENSBUR.Y
BUILDING AND CODES DEPARTMENT {/
BAY & HAVILAND ROADS
QUEENSBURY, NEW YORK I280$
TELEPHONE (518) 792-5832
BUILDING INSPECTOR ' S REPORT
REQUEST FOR INSPE TXON RECEIVED
NAME
LOCATION
DATE Zl -mod/- PERMIT # `/ 7
r APPROVED
YES NO
fI'rFOOTING/PIERS
MONOLITHIC POUR FORMS
FOUNDATION/DAMP-PROOFING
SACKFTL.L APPROVAL
ROUGH .FWMBXNG
FRAMING
ELECTRXCA ROUGH-XN
INSULATION.
FOUNEATIO
FLOORS
WALLS
CEILING
FINAL XNSPECTIO
CHIMNEY HEIG
ROOFING
SIDING
EXTERNAL RCHES/ TEPS
STAIRS--C ARANCE & RAILS
PLUMBING FIXTURES/ LIEF VALVE
INTERIO TRIM/PRIVA DOORS
FINISH D FLOORS''
GARAG FIREPROOFING
DOOR LOSER (S)
SMOK DETECTORS
FINAL LECTRICAL INSPECTOO
FINAL APPROVAL OF CONSTRUCT ON
A SIGN D CERTIFICATE OF OCCUPA Cy
MUST BE
OBTAINED FROM THE BUILDING DEPA TMENT BEFORE
THESE PREMISES ARE OCCUPIED!
REMARKS.&
INSPECTOR
YOGI ARE HEREBY REQUESTEp TO
INSPECT AND ISSUE CERTIFICATES
FOR THE FOLLOWING ELECTRICAL
EQUIPMENT TO BE INSTALLED BY
THE UNDERSIGNED T r r
TEMP. # DATE
CITY OR VILLAt3E TOWNSHIP
/ CIXJNTY
SIREET AND NU OR Ilp
POLE NUMBER
BETWEEN VOW TUM>CROSS STREETS IS PREMISES gyp['/{ 7 SEG7KJN
3 BLOCK LOT
}' X.
CX?CUPANT'S NAME _ n BUILDING OCCUPANCY
�A , a G.r1", ..1 ._' . '
OWNER'S NAME AND ADDRESS f f •T� HOME 7Emet'
HPDNE NUMBER
C
CURRENT SUPPLIED HY ., I'i1pM THEIR OFFICE WORk TELEPHONE NUMBER
BUILDING Is
N OLD ❑ WORK IS NEW ❑ ADDITk7NA ❑ DEFECTS REMOVED ❑
LISF $FLOW ALL EQUIPMENT WHICH YC?U IN'aTALLED
I MA_ k NUMBER OF OUTLETS No. of Fixtures & MOTORS HEATERS BRANCH OFFICE Use
Lamp Receptacles ONLY
lion CIRCUITS
=SwrIch A.YY.O.
Pendant Brsekat Mo. Type Each Na EahNu. GaugeINa�JPErrT EN
OUTSIDE
SUR.
E
MENT
FL.
FL-
FL. _
3rd _
FL.
REMARKS: LIST OTHER ELECTRICAL DEVICES NOT SET FORTH ARCNE:
THIS APPLICATION IS INTENDED TO COVER THE ABOVE-UISTED EQUIPMENT TO BE INSPECTED, BUT IF AT TIME OF INSPECTION, THERE IS
FOUND ADDITIONAL EQUIPMENT NOT ABOVE LISTED, YOU ARE AUTHORIZED TO MAKE THE INSPECTION AND ADJUST THE FEE TO COVER
THE ADDITIONAL EQUIPMENT, AS PROVIDED BY THE APPLICANT.
nVWONK
FEEDERS ELECTRIC SONSA.AfMPS TOTAL NNTTS
CHARACTERORK ❑ EXPOSED CIAO TUBE S1GN/'I'RANSFORMERS OIF y�
❑ oomcEALED
STARTED RATE COMPLETED SIZE CIF SIGN(NUMBER) �pl�,BUILDING MANU❑ OVERHEAD ❑ UNOERGROUNO
ECTION PI ON(OR AS NEAR AS POSSIBLE) MUST ENTER APPLICANTS ! +
IDENTIFICATION NU1116ER .► I I [ I '. I . . f
AI IDID DELAYS BY QMNG FULL AND ACCURATE INFORMATION. ALL SPACES MUST BE FILLED IM CIR APPLICATI N MAY BE
PRINT NAME AND ADDRESS
N7�F gPP ICANT •. AJ3PU�`�T .
STREET ADDRESS _ P }
TELEG^ 'v'C-+'�--
CITY OR P961- 0F10E,r+'+ ZIP CODE -••-- LICENSE NO. WHEN APPLICABLE
Ll 86 John Street ❑ 41 State trees ❑ 584 Delaware Avenue Cl 217 Lake Avenue ❑ 202 Arterial Road
NEW YORK, NY 10038 ALBANY, NY 12207 BUFFALO, NY 1d202 f SOCHESTER, NY 14608 , SYRACUSE, NY 13206
THE NEW YORK BOARD OF FIRE UNDERWRITERS
0� * SSUE ❑ATE .titnR:DD,
wr/
PRODUCER
THIS CERTIFICATE IS ISSUED AS A MATTER .IF INFORMATION ONLY AND CONFERS
NO RIGHTS UPON THE CER T:F!C A- F HOLDER "41S ^_E.R rIF-CA TE DOES NOT AMEND:
Cool Insuring Agency Inc . EXTEND OR AL 'EP T"E '.'+.vERAGE -:FF:Ja;ED BY ^HE ROLIC;ES BELOW.
P . O . Box 2074 —._--------- _-.__---.--
Glens Falls , IVY 12801 COMPANIES AFFORD NG COVI: RAGE
v "� "• ' A
Aetna Life & Casualty Company _ -
Raven Industries
58 McCormack Road D
Lake George , NY 12845 ---- - ---- _-- "---- -
. . E
THIS IS TO CERTIFY THAT POLICIES OF INSURANCE L;STED BELOW HAVE SEEN ISSUED TO -HE !NSURFC '� MED AB(-YE �'�R 7= 'e Pr ,v P cr-arOD INOfCA?Ep.
NC TWITHS T. ANOING ANY REOUIREM€NT. TERM OR CONDITION OF ANY CONTRACT 7R Or HER ^.:-�r;,*AEv ` ry17 �1 PE��EC` _Y „' � .' , r -=t -E R- Iv IC A MAY
BE SSLIED OR MAY DE%; 'AIN THE INSURANCE AFFORDED S'e 7 H E POLICES 0ESC RISE HEREIN S 3' S.,E O Ai_ '.+r V %NC :. .`. `41]I- v
TICNS OF SUCH POL,CIE5 r
GENERAL _:A8p `Y
A i_. 1OMP377378FXH 10 / 6 / 88 10 / 1 / 89 �
x a 300 300
x .. .. 300
A , L:. _ Aa;L:- . 10FJ407341CXH 09 / 7 / 88 10 / 1 / 89
x
500
=ti•CAKERS COMPENSATION - O.IB0932525881 10 / 6 / 88 1O / 1 / 89 = 100
AND " .—_ ... . .
i0D- MP; O� rRS' LIABILITY - - - -- - - - -
^T4£R
'C
r r r •
5HQULD ANY :-)F T- E A -•, ,.'F ^ESCRISEO POLICIES 8E CANC.ELLED BEFORE THE EX-
PIRATION DATE ` HERc � r- T .+E ISSUING COMPA64Y WILL ENDEAVOR TO
Town of Queensbury MAIL 30 DAYS WRITTEN NQ ICE 'O TrtE ERTIFICATE H OEFi NAMED TO THE
Bay & Ravi land Road ..EF- BUT FAILURE TC MAIL N NO T!CE SH L IMPOSE O GA7iON DR LIABILITY ;
OF ANY r(.ND UPON '-i€ COMPANY 'TS AG T R R rP . E'S_ENA�I —
Queensbury , NY 12804 Aur:o ; aEst`.- ; .,E ._. � ,. . �; -- -
4�t VAu 47usar � 57���s
PATU Jv Ll tS, )50 3
F«�a N4t(. z.i 4583
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