1989-577 Zvi
a`
CERPmICATE 1 OF CCC V PA 1 IC'.401C
TOWN OF QCJEENSOURY
WARREN COUNTY, NEW YORK
Late May 29 19 90
.j� Cl lq ' l l L40
This is to certify that work requested to be done as shown by Permit No. 89- 577
has been completed.
This structure may be occup e" a Single Family Dwelling
Location 6#X IXZX Sul l i vaB Place
Thomas & Cynthia Britt
By Order Town Board
TOWN OF QUEENSBURY
Director of Bldg. do Code Enforcement
....I
to
BUILDING PERMIT x
. _ � iti
TOWN OF QU EENSBURY No 89_ 577 a
WARREN COUNTY, NEW YORK
00
r
ha
r
PERMISSION is hereby granted to_ Thomas & Cynthia Britt ,
OWNER of property located at Sullivan Place Street, Road or Ave.
in the Town of Queensbury, To Construct or place a Single Family Dwe 1 l- ng_
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.
m
t. OWNER'S Address is
RR# 1 Box 1724 —'
Y
Lake Georges N . Y . 12845
--I
4
2. CONTRACTOR or BUILDER'S Name Ea
m
v'+
Self :za
c-�
3. CONTRACTOR or BUILDER'S Address
co-
s
Same
4. ARCHITECT'S Name
cn
c
S. ARCHITECT'S Address
�^r.J
T
6_ TYPE of Construction — (Please indicate by X) m
t �7 Wood Frame I I Masonry l } Steel [ 1
M
7_ PLANS and Specifications
No, 28 ' x 46 ' Single family Dwelling as per plat plan , specifications ,
and applications including septic , and driveway .
t.01
B. Proposed Use
co
W
Single Family Dwelling
su
PERMIT FEE PAID — THIS PERMIT EXPIRES February 1 19_90 `^c
(If a longer period is required an application for an extension musk be made to the Building and Zoning inspector of the
town of oueensbury before the expiration date.) ro
J.
Dated at the Town of Queensbury this 26th Day of �- ll V _
SIGNED BY .G r� Ed/ 1 for the Town of Queensbury
Building and Zoning Inspector
TOWN,'M} Oro '�GE,� S (�Y L.• LS. ITOWN OF' nn � . - ,- . . - ^ ter ri i^ r . r � tr,i " • �Vl
QUEENSBURY
R cv i d RECEf VED
Fee Fed t S AL 21 1989
UJILI] INIi 4VO CUDES LA .PAAI"rIEA."F DaCe To,sued
AY and HAVILAND ROADS RD I Liox 93 BLDG. � CODE DEPT.
nUEENSBURY , NElf YORF: 3 2d o -4 ACnmc t MD . 'S q
TeI ( 5181 702.5912 Ext 204 EIRMNO
■ * ,r r r * t r r r •r ■ r • r r s ■ ■ • ■ r r r r r ■ • ■ w • ■ w • r a
A VE- 1 IIT MUST DO OBTAINED UEIf ORE LECI ;� I`IINC, CC� NSTItLlL:TIQhl . NO INSPECTIONS
s'kILL BL HADE UNTIL APPLICANT ItAS i' ZCEIVED A VALID DL' ILDINC PERMIT .
All applicable spaces on this application must be conipletcd and the
r �yaturc of the applicant must al-spear on she reverse sick of this shces
s 'k X X x 7k �k ![ 7t x rs x X tt t x tc it !r • ■ �r s t 1e ft x * At * ft ie tr Yr R X
'1' fie owner of this property is � +i ftcz A c y �
r' . a , Address I X /"T_4' Z ✓�A. �"y 1 �' �i+P er �-L_ r 2 s-h �_T E L .
iroperty location" siI � r1f f► ! 1_/t�+ ,e 64wLj 1 ,�:4ke tAX ttAP ND . �
�'O s1
teas there been any split oe this property since October 1 , 19SS - yes no
2f yes , Planning Board Review is necessary .
cU50IVISIDN tgAMC , Tr APPLICABLE LOT NOW
' he Person responsible for suy .: rvxsion of work as regards Building Codes is :
Ake L
F . G . ADDRCSS LEL NO
NAME
Tel '7rr3
,aume of b"ilder <-Ani. .ae- QA8'O Address ycrg�S ALao J � �rr� �r
:a„ma of Plumber l.darCsSOwns Tel
Tel
N.Ame of Mason
,,tiFuRt Or f�R4!'4MLD W712►. : Z0N1I. C� INJ C� iirt.+.� LON ( Ut fice use on .: y )
�Van � crucciQr+ of .r rsuw buildin.7 ZONINC. MUSICUAT'ION OF PROPERTY
Ad.xitLon to a lauiltlit:g . PERMITTED PRINCIPAL PERMITTED ACCESSORY
�Altur.ation to u lruildinq „ REVIEW REQUIRE CI own PLANNING BOARD. ?.DNING 3C1ARD�
� [ lr❑ ClL..r ..� to ti:xc � rLJr {1iiRCn:: LQn:i �
Uck « r wars: t•1u4.cris�• } ' SITE PLAN REVIEW M APPROVED DATE
: 1aQ55 AkL.+ Cal' 1' ft0i' OSL" Gt. ." 'CCsUt 'I' UFtFr ' VARIANCE P. APPROVED DATE
. tit Floor� � sq ft . Remarks :
' nd f ioor -.---- -- sq f t , i CCs► tl' LL '1'r INI'Oi.ru►'1'iOty Sta:t ullcCO IsuLl,+ra .
3ir.t of proltw 4
rty f `�'b rc x ID ft .
Ocher Floors �--- -- sq ft . w t &tkej 1.;?66il%1. as�3 ( 1 sisu r' t x — rc .
tnot colLur or bssamanc ]
TOTAL FLOOR AREA�Z 2sq f t . • LxsacLa►g oual.lan.] 1w ] Uuw
sons
`g i ::w ur naw �;cructur+ J? 3� f t 1: ,f t `
1'utv,d:. cion-{� icr/ :'13L/ Cr.►wl/1�3rci.. 1/ ui1 ' krQl�a::c arig , dis:.. c..ncw trout 1.s.,7purty ILau
(cirelw one ) + Front y4rd� +�"�? r t itcar y:+rd et
N,.i . of Ctoriea (I►.JUit:abla ;tl)&CQ ) r'f ^�
Sides y;.rd� � '� c ;anti
64jighc curatla to riagQ ) ILV fc ' + Ii on cornur , :,.ucliwak from s1du :;crutcCc
If rauidQncialo no . Of fcmili■sa _
"00 of rocuaat Iexcludinta b:`trist ] (. OCCUPANCY 1NF01`.MATiCN
410. Of bodrooma
� � � PItZMA.RY DVILDINC Own
nov of bacliroow:; on, pn�, fawtsly dwelling
�'riw.ary Itwac itsy s;y::� . ut .r�—N�.1 a i'a c ^i%wo f:.tas.ly dwullany
`;'Yl'•s of Coal ram ! L ��,•— KUICcLlalu Jw"Lli.ng / NtuaDatiC Of ur►itsa
No . aE firutslac.sa: ate law ins:c:all .:d x,,aaU%Anc„t oecup"Ibcy
fiiall :a wuu7d W 60vw tow i�tuCall�s+.17 L'r:ans iuttC ouculua bcof
s'(w:0AC .rl Air sorul.itirsnitkq.' ilusinu:tx
UUILOING STYLE, PRIMARY STRUCTURE 4. Invus>:risl
:•utClx Connstt, :t:r.s Lct2 cafain O !wr
I y
3t wd3isican0 .•sia.t will u::u l�ta7
isalti�:l1 rsnclti run�siutt Dul+lwx
uplat 1%tvwl 014 uzyLa uuiay•alou
C.•iau Cod Cactwca.a i�clwr ' ACCLSSOAY BULL ING—
L`calonirrl itaw 1'ot• t� Flotais ' r✓r:cachau y ar qQ/O cur/ two C:ar/ c;.r
( CI :iCI.E ONL PLkA.�.0 ] ' hct:aehu�► c� �r:a te/ as.s car/ cwo G"rf,___„cus'
• a a ■ s ■ r r r r ■ ■ • . * r ' l�riYwGw SLOr:.t� builclinq
I: S '1' IxAY1: 0 MARKrein V1► l. U [£ �F ' Othwr
COIM ::T itUCT IQ#d i ■
1NFOR►1ATTON ON OUTLOINC SpnCIFICATTONS * ON RZ'VERSE SIDE: of 'TtITS Ct14WTv Trl at CQMPLCTLGI
Fort DPA 10/88 V1
6 [ � Si aG SPE,vIFCC.:'" [ O74s
:y f cor. struct : on , woos' frame , Ice Vale , etc .
any se.=cnd- hand or ungraded I .. ter --Oa used .' �G , .'] � 4Y - P: � T'1 c::)
=U :.ndl tlon wall material T� Eck ass /p
Lepth of foundation below grade k - o t,ct -cm of footiing )
wilt there be a cellar ' "rstew or unheated ? i7v i Feet~ Floor sq . footage I A ws;� �sq ft
Will there be a basemen d 00-Will any portion be used as living space ?_ 134=>
( If so , what portion? sq , ft , _ _ ._ e of use ?
Tyre of roof— sloped flat/shed/ot: er Material of oof S r '
vice , woad studs" X�(L" spacing " o . c . length '�gt r
)casts ( floor beams ? Ist , floor C " Sc " spaci a_4 o , c . span ft .
JoiSts ( floor beams ) 2nd . floor " x " spacing — go span -- Et .
�verlayys ( ceilinq beams ) rt _,' x L spacing, "o . c . s,pan �ft .
Root rafters " x spacing C . C . span ft .
RpGf trusses ( Are- engineered ) spacing H " o . c . s an oly ft .
Exterior wall finish Of what material ? E � --
Interior wall finish
If a garage is to be attached , describe materials to be used for FIRE SEPARATI:' .i :
Is there to be an opening between garage and dwelling ? If so will a Fare - rated
door , enclosure , and self-closing device be provided ?
Will a flue - lined chimney be installed? Height above roof ft .
Depth, of chimney foundation below gradert�ft ,
Depth of fireplace hearth ft . — in .
water supply - Municipal or ,private well� � �
SEPTIC SYSTEM _ Distance from ANY private well ( including adjoining properties /nC7 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 wort: shall be complied with , whether specified
or not , and that such work is authorized by the owner . c �
Signature
Owner, owner's agent, architect , contractor
SPECIAL CONDITIONS OF THE PERMIT :
By
TOWN OF QUEENSBURY
WAR'REN . 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 bccy1BR 2 , Type of heat Q1
3 , is the building mechanically cooled ? Ip c�
b
4 . Percentage of area of windows and doors f�t '�"/1
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
5 . Type of insulation
B . Under 16 % only
VMW
1 . R v lue of roof and floors exposed t ambient conditions_
2 , R value of exterior walls _ 19
3 . R value of glazed area_A _ Q �l"1 �a {c � � fs'1�"► _r ��
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 )
9 . R value of heated basement /cellar walls ( below grade )
10 Type of insulation�i [3� S ),a SS -a � �-� r-� ( erg,
C . Controls
1 . Thermostat maximum heat setting_
D . Duct Systems__
1 . Is duct system installed in unheated spaces ? YES -_.. 0 '
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 pipet/
2 , R value of pipe insulation
F . Service Water Heating
i . Performance efficiency
2 . Temperature control setting maximum f , Z?
G . For Swimming Pool Onl_ _y
1 . Maximum heating
Telephone No . 29._3 —c9e�5ss" �-' t1l�`�� A
( applicant ' s signature )
-� "
VAr -
APPLICATION FOR
vx �` SEPTIC DISPOSAL PERMIT
DATE/
LOCATION OF PROPERTY FOR INSTALLATION.
Owner's Name: �I ,�y^p.ry �gs A1 1� �� Telephone. F? 9,3 — < QC? —
Address:
Installer's Name: Telephone: 293 --65;aS'
Number of bedrooms (residential only) _
Total daily flow (compute (a 150 gal per bedroom) 050/ `z-:
Topography: Circle oneLF Rolling Steep Slope % of Slope
Soil Nature: Circle on Loam Clay Other --- /Depth : — Feet
Ground Water: At what depth? Feet
Bedrock or Impervious Material: At what depth ? /rajj Feet
Percolation test: Circle one: Cat requirSW required rate min. inch.
Domestic water supply: circle one: Municipal el Other
If domestic water supply is a well:
Separation: Water supply from septic absorption f) C) feet
PROPOSED SYSTEM : Septic Tank . &CJ, gal. ( minimum size: 1 , 000 gal. )
TILE FIELD : Each Trench J�u feet/Total system length o' q'c feet
SEEPAGE PIT(S): Number of / Size each feet by - feet
Size of stone to be used # ; /Depth or Thickness feet
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 Queensbury Sanitary Sewage Disposal Ordinance.
SIGNATURE OF RESPONSIBLE PERSON: r,Q—m, �l ,Z7
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 t3-ke 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
1uilding 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 CODES DEPARTMENT
Flay and Haviland Roads
Queensbury , New York 12804
K� marks ;
TOWN OF QUEENSBURY
BUILDING AND CODES DEPARTMENT 11
BAY & HAVILAND ROADS
QUEENSBURY, NEW YORK 32804-
TELEPHONE (5I8) 792-5832
BUILDING INSPECTOR' S REPORT
REQUEST FOR INSPECTION RECEIVED
NAME
LOCATIONy r�
DATE PERMIT
APPROVED
YES NO
FOOTING/PIERS
MONOLITHIC POU FORMS_
FOUNDATION/ PROOFING s
BACKF'ILL APPRO L
ROUGH PLUMBING
FRAMING
11
ELECTRICAL ROUG XN
XNSULATXON:
FOUNDATION
FLOORS
WALLS
CEILING
VFZMAL XN.SPFsL^TIONr
CHIMNEY HEIGHT
ROOFING x.-^
SIDING rr
EXTERNAL PORCHES/ TE S
STAIRS—CLEA=aANCE ILS
PLUMBING FIXTURES LIEF VALVE
INTERIOR TRIM/PRITT CY DOORS c
FINISHED FLOORS
GARAGE F3JZEPROOF,,T G _
DOOR CLOSER (S) f
SMOKE DETECTORS rr —
FINAL ELECTRICAL TION
FINAL APPROV Ct7NS FtUCTI
OK TOISS C/O R .CfC
A SIGNED CER rFXcATE OF r CUPANCY MUST BE
OBTAINED PROM THE BUILDING DEPARTMENT BEFORE
THESE PREMISES ARE OCCUP EDI
REMARKS:
ARRIVE
DEPART_ _
INSPECTOR
TOWN OF QUEENSBURY
BUILDING AND CODES DEPARTMENT
BAY & HAVILAND ROADS
QUEENSBURY, NEW YORK 12809 .
TELEPHONE (51B) 792-5832
BUILDING INSPFCMR ' S REPORT
REQUEST FOR INSPECTION RECEIVED 04*�w �,ap 7-
NAME 00 40*7
LOCATION
DATE -�/'� — /PERMIT # r
f APPROVED
a M YES NO
FOOTINGIPIE 9
MONOLITHIC POUR FO S
FOUNDATSON/DAMP-PR FI
BACKFILL APPROVAL
ROUGH PLUMBING
FRAMING
ELECTRICAL ROUGH-IN
FOUNDATION
FLOORS
WALLS
CEILING ( -
FINAL INSPECTION:
CHIMNEY HEIGHT
ROOFING
SIDING
EXTERNAL PORCHESfS E
STAIRS-CLEARANCE RA LS
PLUMBING FIXTURE RELEF VALVE
INTERIOR TRIM/PR ACY DOORS
FINISHED FLOORS
GARAGE FIREPROO ING
DOOR CLOSERS)
SMOKE DETECTO
FINAL ELECTRICA INSPECTI
FINAL APPROVAL F CONSTRUC ON
A SIGNED CERTIFICATE OF OCCU NCY MIDST BE
OBTAINED FROM THE BUILDING DE RTMENT BEFORE
THESE PREMISES ARE OCCUPIED!
REMARKS:
"fir �f ti
/ CJ
INSP TOR
TOWN OF QIJRY
BUILDING ANDD CO CODESES DEPARTMENT
BAY & HAVILAND ROADS
QUEENSBURY, NEW YORK 1280+R
TELEPHONE (5I8) 792-5832
BUILDING INSPECTOR ' S REPORT
REQUEST FOR INSPECTION F;ECErVED
NAME
LOCATION/
DATE _ l f �! PERMIT #k
APPROVEDa+�
YES NO
FOOTING/PIERS
MONOLI2wHI6 POUR FORMS i r
FOUNDATION,YDAMP—PROOFING
BACKFILL AF�PROVAL llp
RqUGH pL,TJMB NG .
NING
ELECTRICAL R UGH—IN
INSULATION:
FOUNDATION
FLOORS i
WALLS
CEILING ;
FINAL XNSPECTIO16
CHIMNEY HEIGNIX
ROOFING it
SIDING,
EXTERNAL PpRCH.ES1$TEPS
STAS.RS—CLSARANC'E &k'ERAILS
PLUMBING IXTURES/RIEF VALVE
TNTERIOR,e TRIN/PRIVA DOORS
FINISHE]$ FLooRS
GARAGE jXREPROOFXNG
DOOR CF,:OSER (S)
SMOKE DETECTORS
FINAL ELECTRrCAL .INSPECTION
FINAL APPROVAL OF CONSTRUCTION
A SIGNED CERTIFICATE OF OCCUPANCY MUST BE
OBTAINED FROM THE BUILDING DEPARTMENT BEFORE
THESE PREMISES ARE OCCUPIED!
REMARKS:
V
INSPECTOR
,jcrtun a/ �ueerr36urc�
BUILDING and ZONING DEPARTMENT
Bay and Havifand Road, R.D. I Box 98
Queensbury, New York 12801
SEPTIC DISPOSAL SYSTEM INSPECTION
NAME T - �' �r
LOCAT I ON
DATE -f��/ PERMIT No.
SOIL TYPE - Sand - Loam - Clay
Percolation Test Required ? YES - NO
Percolation rate - Min/Inch
TYPE of SYSTEM : 7
Absorption field , total . .ength /�" �"
Length of each trench i �
Depth of trenches
Size of grave]:_
SEEPAGE �'TTS{Number of
Size- ft . X ft .
Gravel size
PIPING : Size. T pe
Bldg . to tank
Tank to (list . box
Dist. bo7: to field/
Openings sealed? E+INIO Partial
T OCATION/'SEPARATIONSS :J+
Foundation to tank fto
Foundation to abscr Ation � ft .
Absorption to lot �ne ft'
Separation of pats
ON CSF SYSTF ON PROPERTY (c ' c1e one )
ont - Rear ea- LE -t side t side -
TS :
SYSTEM USE APPROVE Fin
NO
Buinspector
01/86 and vl
TOWN OF QUEEINSBURY
BUILDING AND CODES DEPARTMENT
BAY & HAVILAND ROADS f �'
QUEENSBURY, NEW YORK I2$Q
TELEPHONE ( 518) 792-5832
BUILDING INSPECTOR' S REPORT
REQUEST FCJ�1.4.�Iv/N�SPECTXON RECEIVED
J/! P� � �NAME i
.L,OCATION y - �c �j
DATE
PERMIT # 4 f — 6 2 /
APPROVED
YES NO
FOOTINGIPaTERS
MONOLITHIC POUR FORMS
C -' OUNDATSON/DAMP ROOFING
,,.,.�'ACKFILL .APPROVA
ROUGH PLUMBING
FRAMING
ELECTRICAL ROUGH-I
INSULATION:
FOUNDATION
FLOORS
WALLS
CEILING
FINAL INSPECTION :
CHIMNEY HEIGHT
ROOFING
SIDING
EXTERNAL PORCHES/ BPS
STAIRS CLEARANCE & RAI _ --...--
PLUMBING FIXTUR S/RELIEF ALVE
INTERIOR TRIM/ RIVACY DOO
FINISHED FIAO S -
GARAGE FIRED DOPING
DOOR CLOSER S) ._.
SMOKE DETE TORS -
FINAL ELEC ICAL INSPECTION
FINAL APPR AL OF CONSTRUCTION
A SIGNED CERTIFICATE OF OCCUPANCY MUST BE
OBTAINED FROM THE BUILDING DEPARTMENT BEFORE
THESE PREMISES ARE OCCUPIED!
REMARKS :
Pgoocf
J
INSPECTOR
TOWN OF QUEENSBURY /af v /
BUILDING AND CODES DEPARTMENT
SAY & HAVILAND ROADS
QUEENSBURYo NEW YORK 12804-
TELEPHONE {518) 792-5832
BUILDING INSPECTOR' S REPORT
REQUEST FO INSPE TION RECEIVED --
NAME I ,
LOCATX N
DATE PERMIT #
APPROVED
YES
FOOTING/ ZERS
MONOLITHI POUR FORMS
FOUNDATION P—PROOFING
BACKFILL APP VAL
ROUGH PLUMBING
FRAMING
ELECTRICAL ROUGH—I
INSULATION:
FOUNDATION
FLOORS
WALLS
CEILING
FINAL INSPECTION:
CHIMNEY HEIGHT
ROOFING
SIDING
EXTERNAL PORCHES/ST PS
STAIRS—CLEARANCE & RAILS
PLUMBING FIXT'UREOS eRELXEF VALVE
INTERIOR TRIM/P VACY DOORS
FINISHED FLOG _
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
YOU ARE HEREBY REQUESTED TO
d INSPECT AND ISSUE CERTIFICATES
FOR THE FOLLOWING ELECTRICAL
EQUIPMENT TO BE INSTALLED BY
THE UNDERSIGNED
CnY OR AL 1511111:1 111 i:: ------------------—
WWNSHIF! COUNTY
STREET AND -G L isl I .,�.d I` - , i N.
d
Pol Aflubi
BETWEEN ATW TWO Cni SMEL73 IS Fill ISES LOCATED9
SECTION CLOCK
LOT
BUILDING'OMUP4mCy Idl'
OWNER'S NAME AND ADDRESS 11
TELEPHONE NUMBER
d
FROM THEIR de ddl- 1c,CURRENT SUPPLIED BY d;
k x VA7RK TELEPHONE NUMBER
BUILDING M
New El OLD El WORK IS NEW ADDITIONAL
UST BELCYW—A VEFEC15 REMOVED
�L EQUIPMENT STALLED
Loca- NUMBER OF OUTLETS Na. of IIIXTUres aMOTIORS Lamp ReceptaclesHEATERS BRANCH lionITS OFME USE
s4de Attach I ONLY
Ceiling Waif FteldXIp'lls awl" Panidjank -I AWG.
OUT- Each G*tuge INSPECTION
SIDE
SUB-
Ell
Eld
MENT
Ist
FL-
2nd
REMARKS; LIST OTHER ELECTRICAL DEVICES NOT SET FORTH Ael 1 11 M.
TION IS INTENDED
THIS
ADDITIONAL
APPLICATION EQUIPMENT COVER THE ABOVE•LISTED EQUIPMENT TO BE INSPECTED. BUT IF AT TIME OF fNSPECTIQN, THERE IS
FOUND ADDITIONAL E Idr L
E ADD NA EQUIPMENT, F
OT Af30VE LISTED, YDU ARE AUTHORIZED TO MAKE THE INSPECTION AND ADJUST THE FEE Tt3 COVER
H
ROVIDED BY THE APPLICANT.
SUE OF MAINS FEEDERS ELECTRIC SIGNISILAMPS ELEC`IdR� MGNWLAMPS
ITMI,V*WTS
c ER Or
"R
❑ EXPOSED Ed TUBE SERllTRAN SFORMEAs op
1�49AI El COWEALED
�GE
DATE V0044K TO HE STAR EWWE 0OMPLrTED SIZE OF SIGN INILIMUE CAPACITY
SERVICE ENTERS BUILDING
OVERHEAD UNUERQAOl MAN UFACTURER OF SIGN
DATE INSPEORONI AEul 4dX4 M�R AS I'll A�S POSSIBLE}
ppi
_ dd,
MUST IMITERAppilw"i Mi
ddddddddd..� mill
Mem"Idw:1111(wili Oboi0lbA
PRINT NAME AND ADDRESS LICAT111i NAX,@F��gji
NAME OF APPLICANT
DATE OF APPLICATION ell,
W
d APIPIJ—rAllff
11 dd,
STREET ADDRESS = Y0 .,;# ddI elf j
LEPHONE NO.
d I L
0Qd
CITY cill
d/ q k Odd — p ZIP CODE LICENSE O.
WHEFTA�PMACABLr
EJ 85 John Street El 41 State Street 0 570 Delaware Avenue ❑ 217 Lake Avenue ❑ 202 Arterial Road
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THE NEW YORK BOARD OF FIRE UNDERWRITERS
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