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1989-778 ` ri v • ..�' ► �" '6 .� .. I}I CERTIFICATE 01F OCCUPANCY TOWN Of QUEENSBURY WARREN COUNTY, NEW YORK Bate '/ % ' 19ALS This is to certify that work requested to be done as shown by Permit No. 89- 778 has been completed, This structure may be occupied as a , . .,. Auld l t-j n n t n Ono Fri m i I Lxpcat;ork 15 Brookshire Trace I Owner Pat & Marie Burke f By Order Town Board VPWN OF QUICIEZ48BURY I f Building & Zoning Inspector i I i �- BUILDING PERMIT TOWN OF QUEENSBURY No 89_778 WARREN COUNTY, NEW YORK r cs PERMISSION is hereby granted to Pat & Marie Burke v OWNER of property located at _ la Brookshire Trace Street, Road or Ave. in the Town of Oueensbury, To Construct or place a _ Addition to One family 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. 1 . OWNER'S Address is d C: Same a n V 2. CONTRACTOR or BUILDER'S Name Norman Ouellette s� 3. CONTRACTOR or BUILDER'S Address rt 4. ARCHITECT'S Name 6. ARCHITECT'S Address f t 9 C 6. TYPE of Construction — IPleass indicate by X1 c V 11 Wood Frame ( ) Masonry i T Steel ( I r 7. PLANS and Specifications ' No, 496 sq . ft . addition to one family dwelling as per plot plan , specifications , and applciation . ` S. Proposed use Addition to Single Family $ 40 00 PERMIT FEE PAID — THIS PERMIT 'EXPIRES May 1 19 90 (If a longer period is required an application for an extension must be made to the Building and Zoning inspector of the f town of Queensbury before the expiration date_) Dated at the Town of Queensbury this l lth Day of October 19 89 r 4 . ; SIGNED BY X /1y / —aY . n_�- for the Town of Queensbury ! Building and Zoning Inspector c TOWN OF QUSENSBURY REVIEWED BY�/G FEE PAID PERMIT NCI. cat BUILDING PERMIT APPLICATION BLDG. & CppE DEP'r A PERMIT MUST BE OBTAINED BEFORE BEGINNING CONSTRUC.'TION. NO INSPECTIONS WILL HE MADE UN'M APPLICANT HAS RECEIVED A VALM BUILDING PERMff. All applicants spaces on this application MUST be completed and the signature of the applicant MUST appear on the reverse side of this application. The owner of this property is: "/%� �. C /� i f.r, P.O. Address r1 S J ?, ` ' _' :F Tel. Property Location C z r .: 3 i/ ,"�y Tax Map No. Has there been any split of this property since October 1 , 19889 / If yes Planning Board Review is necessary. yes no SUBDIVISION NAME, IF APPLICA@LE r !' r` ) L r LOT NO. THE PERSON RESPONSI@LE FOR SUPERVISION OF WORK AS REGARDS TO BUILDING CODES IS: * NATURE OF PROPOSED WORK: ESF;MATED MARKET VALUE OF Construction of a new building » CONSTRUCTION : S `f /�� Addition to a building * COMPLETE INFORMATION REQUIRED BELOW: * Size of property / G ft x eft, Alteration to a building * Existing Buildings( 3) Size L' ft. x d` jo ft. (no change to exterior dimensions) * -, Proposed building - distance from property lines Other work (Describe) " Front yard / c] 3 ft. Rear yard ft. * Side yards ft. and t"� ft. GROSS AREA OF PROPOSED STRUCTURE * it on earner, setback from side street ---ft. 1st Floor 4/ `w s ft. q' OCCUPANCY INFORMATION 2nd Floor - sq. ft. * Primary Building Other Floors sq. ft. * One Family Dwelling (not cellar or basement Two Family Dwelling TOTAL FLOOR AREA t ;- a sq. ft. * Multiple Dwelling/Number of units * Business Size of new structure ft x e ' ft. industrial • Foundation-pier/slab raw partial/full (circle one) " Other No. of stories (habitable space) Height (grade to ridge) I3 ft* * If addition, what will use be? If residential. no. of families ' * r Y f f: f`• v f. f No. of rooms(excluding baths) ' � • Accessory Building No. of bedrooms d:' " Detached Garage ONE/TWO Car No. of bathrooms Z� Primary heating system -- * Attached Garage ONE/TWO Car Type of fuel " Private storage building No. of fireplaces to be installed * Other Will a wood stove be installed Central Air conditioning -- O V'` ER BUILDING PERMIT APPLICATION CONTINUED - BUILDING 5P £ CIFICATIONS: Type of construction, wood frame, fire safe, etc. Will any second-hand or upgraded I<< mberbe used? If so, for what ? r '�f• r �� ` , Foundation wall material ( _ , , ,< Thickness ,/O, Depth of foundation below grade (to bottom of footing) _Will there be a cellar? f Heated or unheated? -- 4 Floor sq. footage sq ft . Will there be a basement ? i4 Will any portion be used as living space ? (If so, what portion? % sq ft . Type of use? r_ Type of roof slo e-dYflat/shed/other Material of roof Size, wood studs } "x--(e." spacing.,66 IT o. c. length_ ft. Joists ( floor beams) ist floor :.z "X..Z spacing "o.c. span ft. Joist (floor beams) 2nd floor " spacing - - "o. c. span - - ft. Overlays (ceiling beams ) "x " spacing -- " o.c. span ft . Roof rafters "x IT spacing � o, c. span ft. Roof trusses (pre-engineered) spacing t- " o. c. span le; ft. Z. Exterior wall finish ! �^ o 4i 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 afire-rated door, enclosure, 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 SEPTIC SYSTEM Distance from ANY private well (including adjoining properties ft. (A separate application is necessary for any repair or new installation of septic system) NAME OF BUILDER /7/�/ fyi t? r ; � ADDRESS= , e TEL. NO. NAME OF PLUMBER ADDRESS I TEL. NO. ---- NAME OF MASON ADDRESS TEL. NO. - - NAME OF ELECTRICIAN ADDRESS TEL. NO. _ DECLARA iJON To the best of my knowledge and belief the statements contained in this application, together with the plane and specifications submitted, are a true and complete statement of all proposed work to be done on the described premises and that ail 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. / Signature c Owner, owner's agent, architect, contractor SPECIAL CONDITION'S OF THE PERMIT: BY TOWN OF QUE - _4SFJUik : i 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 . ANSWalt ALL of the following : 1 . Gross ! loot area 2 , Type of 3 . Is the building mechanically cooled ? 4 . Percentage of area of windows and doors A . Over 16 % Only 1 . Uo value of gross area of walls , roof / ceiling and floors exposed to ambient conditions 2 . Floor over heat - 3 spaces YES NO a . Are foundat on walls insulated ? YES NO 1 . If YES , what is the R value ? 3 . Slab on grade YES NO a . If YES , wh . t 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 8 . Under 16 % Only 1 . R value of roof and floors exposed to ambient conditions. 2 . R value of exterior walls , 3 . R value of glazed area C -�-- 4 . R value of doors ,_ z? 5 . R value of floors over unheated spaces E� 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 ) - 14 . Type of insulation , • ' � ' i ,, . '> , -, ' C . COntr'O1N 1 1 . Th,trsastat nauimuis heat setting D . Duce srsitsss i . in duct system Lustailed in unheat.+ad spaces ? AYES 110 a . If yZ50 a valise of duct lust'AilatLon b a A v& Lue at duct in other .areas -- --- Piping Insulation 1 . size of hot water or cooling carrying agent pipe al*'.*"e-0/eo 2 . R value of pipe insulation GJ F4 Service water Heating 1 . Performance efficiency_ r] 2 . T*nperature control setting MAXIMUM. l G . For Swimming Pool Only 1 . MAXIMUM hoatingw / Telephone No . 'Q," ( applicant ' s signa ure ) TOWN OF QUEEHSBURY 531 BAY ROAD Age QUEENSBURY . NEW YOR�512804 TELEPHONE ( - 4447 BUILDING INSPECTOR' S REPORT FINAL INSPECTION REQUEST FOR INSPECTION RECEIVED LOCATION :7�j,F� � DATE PERMIT# UL�!-'- -- TYPE OF STRUCTURE ,� RECHECK � '� ' ' wr"" �FI���Q MARSHA APPROVAL ( CO MERCIAL STRU IRE ) i;M(,y NG ING tiM INGDATIOINAL E ECTRICAL� EPTIC _ INSULATION �WOODSTOVE/F REPLACE REMARKS PPROVAL A YES NO CHIMNEY HEIGHT/LOCATION B VENT/LOCATION PLUMBING VENT ROOFING SIDING DECK/PO CH/S EPS /RAILINGSi RELIEF VALVES FURNACE/HOT WA ER OPERAING BASEMENT INSULATION/DUCTWO INTERIOR TRIM/ PRIVACY DOOR FINISH FLOORS : BATH/KITCHEN WATERTIGHT OTHER FLOORS SWEEPABLE OTHER FLOORS CARPETED STAIR CLEARANCE/RAILIN HANDICAPPED ACCESS SMOKE DETECTORS BATHROOM FANS/WHOLEH SE ANS ALL PLUMBING FIXTURE OPERATI G� GARAGE FIRE 'PROOFINC+� --- DOOR CLOSERS OTHER FIRE SEPARA I N FIRE/DEMISE WALLS DUMPSTER SITE PLAN/V R ANG REQl1IREMEN FINAL ELECTRICAL OK TO ISSUE C/O R C/ GOMMEN S : ARRIVE c - � DEPART j INSP ., TOWNS OF QUEENdSBURY BUILDING AND CODES DEPARTMENT BAY & HAVXLAND ROADS QUEENSBURY, NEW YORK 1280k TELEPHONE (51.8) 792-5832 ?'f3'57 3 4 BUILDING INSPECTOR'S REPORT REQUEST poR INSPECTION RECEIVED NAME LOCATl"ON ,r,r--� DATE _ / 7 PERMIT # / _% APPRCIVED YES NO FOOT-TNGIPIERS MONOLITHIC POUR FORMS FOUNDATION/DAMP-PROOFING BACKFILL APPROVAL ROUGH PLUMBING FRAMING ELECTRICAL ROUGH XN INSULATION; FOUNDATION FLOORS WALLS CEILING FINAL INSPECTION: CHIMNEY HEIGHT ROOFING SIDING EXTERNAL PORC S/ TEPS STAIRS-CLEA CE RAILS PLUMBING F TURES LIEF VALVE INTERIOR IM/PRIVACY DOORS FINISHED FLOORS GARAGE FIREPROOFING DOOR CLOSERS) SMOKE DETECTORS FINAL ELECTRICAL INSPECTION FINAL APPROVAL OF CONSTRUCTION OK To ISSUE C/O OR C/C A SIGNED CERTIFICATE OF OCCUPANCY MUST BE OBTAINED FROM THE BUILDING DEPARTMENT BEFORE THESE PREMISES ARE OCCUPIED! Rr&mARKS: A4 rvs 7Z� =�a0 'PA 'G ARRIVE I PECTOR MIDDLE DEPARTMENTANSIRIMMON AGENCY, INC. _ Ii00 IrdSPEQuB `` r� � . "/,{] Daley May 20 , 1994 ¢Ctl tP$ that je�,q equipment fisted has been x�r11 e a approved as being in accord with the National Elect ' J djj al5plicable governmental, utility arid., ��y es. � owner: Marie Burke � pcn occupant: Same Location: 15 Brookshi i 1C B , MeA,J61111111111h... ca ryficata ittowle ric ipmenl and installation insnacfad this date_ If additional LI0 in ah be intF*6uCad or aiierarvons trade to existing system tW c Ica be nuli and void. and application for Equipment: 33 Outlets ; ceptacles ; 1�yFixtures inspection annul A submitt + asi PFIrla+der of this ice fixate a Id ant "me to his prnpnrtY insurange carrier "{'age It o r comppnv)a a evil rH fication of electrical equ i pment approved an apecified. J Marie Burke Burke Applicant: 15 Brookshire Tr "11 • L `!�3 _._ 0 LQueensbury , NY 12$0 16-030057 +rwr• v v Fartst No. Tp3 !L 7 -97 TOWN OF QUEENSBURY BUILD-rNG AND 14, CODES DEPARTMENT 13AY tsr ffAVILAND ROADS QUEENSBURY NEW YORIC 12809, TELEPHONE (5I8) 792_5832 BUILDING INSPECTOR ' S REPORT rLJ+ REQUEST FO INSPECTION RECEIVED NAME k Kig ` LOCATION DATE d . `^ PERMIT I � . APPROVED YES NO FOOTINGfPIERS '. MONOLITHIC POt74 FORMS FOUNDATION/DAMP.PROOFI NG BACKFILL APPROVAL RO H PLUMBING MING ELECTRICAL ROU Ht2 INSULATION: FOUNDATION FLOORS WALLS CEILING � FINAL INSPECTION: CHIMNEY HEIGHT i ROOFING SIDING EXTERNAL PORCHESfa E S .STAIRS-CLEARANCE &'IAILS PLUMBING FIXT'URES12,ELTEF VALVE INTERIOR TRIMfPRXvAcy DOORS -- FTNITSHED FLOORS GARAGE FTREPROOFyNG DOOR CLOSER(s) SMOKE DETECTt?RSi FINAL ELECTRTCALlTNSPECION FINAL APPROVAL CiF CONSTRIPCTION 1 A SIGNED CERT FICATE OF '� UPANCY MUST, BE OBTATNED FRO THE BUTLDTNCCDEPARTMENT BEFORE THESE PREMT S ARE OCCUPIE�! REMARKS: few INSPECTOR ��� TOWN OF QUEENSSURY BUXLDXNG AND CODE'S DEPARTMENT DAY & HAVXLAND ROADS OUEENSBURY„ NEW YORK 12809 TELEPHONE (518) 792-5832 BUILDING INSPECTOR ' S REPORT REQUEST FOR INSPECTION RECEXVED NAME � — LOCATXON / .t r7 /C DATE lei��i S'J/F_ PERMIT #� APPROVED-- FOOTINGjPIERS YES NO MONOLIT"HXC POUR FORMS FOUNDA TXON/DAMP—PROOFXNG BACKFILL APPROVAL ROUGH PLUMBING FRAMING EL' !rRICAL ROUGH—IN r,—�SULATXON.: FOUNLIATXON "' { FLOORS WALLS c cEXr,zNG FXNAL INSPECTION: CHIMNEY HEIGHT ROOFING SXDXNG EXTERNAL PARCH jSTEPS STAIRS-CLEARANC XyS PLUMBING FIXTURE LIEF VALVE INTERXOR TRIMJPRI Y DOORS FXNISHED FLOORS GARAGE FIREPROOF NG i--�- DOOR CLOSER ('S) SMOKE DETECTORS FINAL ELECTRICAL XNSPECTION FINAL APPROVAL OF CONSTRUCTXON A SIGNED CERTST BE IFICATE OF OCCUPANCY OBTAINED FROM THE BUXLDING DEPARTMENT BEFORE THESE PREMISES ARE OCCUPIED! REMARKS: r .INSPECTOR TOWN OF QUEENSBURY BUILDING AND CODES DEPARTMENT BAY & HAVILAND ROADS QUEENSBURY. NEW yoRK 2280¢& TELEPHONE (518) 792-5832 BUILDING INSPECTOR ' S REPORT REQUEST FOR INSPECTION .RECEIVED NAME" LOCATXON DATEFERMIT #� G r . ,�I �/!¢2 APPROVED _ YES NO FOOTING/PIERS MONOLITHIC POUR FCpRMS FOUNDATTOMIDAMP—P ]FING BACKFXLL APPROVAL LWOROUGH PLUMBING LAI�AMXNG ELECTRICAL ROUGH—.IN`; INSULATION: FOUNDATXON FLOORS WALLS CEILING g FINAL INSPECTION: CHIMNEY HEIGHT ROOFING SIDING s EXTERNAL PORCHES/STE,p'S STA I"RS—CLEARANCE & RAk LS PLUMBING FIXTURES/REL EF VA,L—E XNTERIOR TRSM/PRIVACY )DOORS FINISHED FLOORS GARAGE FXREPROOFTNG DOOR CLOSER (S) SMOKE DETECTORS : -}}-- FINAL ELECTRICALNSPECTIL3N FINAL .APPROVAL OFF CONSTRUCTION A SIGNED CERT-rFXCATE OF OCC!}PANCY MUST BE OBTAINED FROM 7WE BUILDXNG DEPARTNENT BEFORE TFIESE PREMISES' ARE OCCUPXED! REMARKS: (�b - 1 1 -T9(X<S 1035 NSPEFCTOR TOWN OF QUEENSBURY BUILDING AND CODES DEPARTMENT BAY & HAVILAND ROADS QURENSBUR'Yr NEW YORK 12804& x TELEPHONE (518) 792-5832 xe:;70 BUILDING INSPECTOR ' S REPORT REQUESV OR INSPECTION RECEIVED NAME _ LOCATION / DATE - JAI /� PERMIT APPROVED YES NO ,V FC702'SNG f PI ERS `f MONOLITHIC POUR FORMS FOUNDATION/DAMP-PROOFING BACKFILL APPROVAL ROUGH PLUMBING FRAMING ELECTRICAL ROUGH- INSULATION: FOUNDATION FLOORS WALLS CEILING t FINAL INSPECTION: CHIMNEY HEIGHT ROOFING SIDING EXTERNAL PORCHE STEPS STAIRS-CLEARANC & RAI PLUMBING FIXTU ES/RELIEF 'lALVE INTERIOR TRIM XVACY DOO FINISHED FLO S GARAGE FIR EP OOFING DOOR CLOSER S) SMOKE DETE RS FINAL ELECTR CAL INSPECTION FINAL APPRO AL OF CONSTRUCTION E A SIGNED C RTIFICATE OF OCCUPANCY MUST BE OBTAINED F THE BUILDING DEPARTMENT" BEFORE THESE PREMISES ARE OCCUPIED! REMARKS : CQ GQA 0 �L) 24, INSPECTOR thVI SO Nationmi Headquartem 800 Hkctrlo6 Ave.,ve., 'Gbllingswood, N.J. 08TOe " Dates City, Town or Township__ ewl f�. cs Aa ... _County k1[d y"r-. r1 State / Location/Address (If Located in Rural rea - Please ,Attach Direetitins) _ I#„ � Owner. ire r- — Occupied As 1raxrrE # f Occupant . : : _, urhdrng OIcFQ "`Wd Area in`Bui in Floor #, etc. : rnb ted- Service or: Rea or-Itad - $ Cash Check °f ph V�iiAng' lets Elect. Heat oa 7eo la 1 1 aoa2xae20 ssaoa000 Amp. SerWcwi � ; - ; a6ifmtejJnit' Dishyliiiirliiir 4 �Q Receptacles Water Heater Air-Conditioner ` x ,.Y... Dryer :� ' S 'fir t Num ' o `Fi ` ` Oyes4 r =- bage Disposal" .Wi rink4ond Cor+trols for. ���tirner L . ierael(ltaelei r= ' .r .- , Oractional H.P. Vent Fans 3' Other Equipment: - Mark 2 1! �y s/a a/e 1/4 .11s II"d 31M1 a 1�!r 2 3 4 Q ': 7kfx: ;a 15 2O 2s . Sa': . {i 7'rf of Each Size x 3 Appli�,rs t = L Signature T/A M` 4A F i #�tY: Applicant' Address: :'P + N i�+tY> +' IState)" Ili Service Requ 1! - Phx>ta _ ` Ei 60 DA RECEIVED: UAIEINSPErcf Correct Location: Same as Above 0 or: , -,? . _ a im" Red Notice Label y Rough ►Miri=nt Surface' Unit ., .. Oyes SwitchesRan � _. s Receptaclesr Heater Fixturesit Gondi ita er"' Amp. ServiEquipmentBurner, rii►g` Miois .for Arn ServiPu Vent Fan . MpTORS H.P. 11/20, 1n2 0 2/a 1 a/a 1/3 1 rz / a 1 ¢' P/r 10 - as 2a g3 F5 Mark Number { .� . 4' I;i . + . � , . of Each I - Elect. Heat aoc Leo love tzso 157p ilea a000 aaSe may . aoro r:�. '? f:t r 4„ iY. ,Rkll Progress: Inc. L"!J Lk;D Contractor j. L9� CFT Violation: Work Comp. © ,: L/A `Owner 'GASH _ . _ . 14t_. . at ■!.� Fee CHK. .�F i ! Y ITI Lini,C.ipal . *ry._. r - DL�e. may. _.. j.i'. r ] .. . . �-,}. ff4 ' - i s dB' 't ._.",_ "13'tl#ity- .f 411g • -�.Cut in Card Temp y ,... elk . - v . Date. .> n a: P4. Final hate F ? ' - RPPLI4`:471C]N RC1-R rN NO. .23{#: .- ypU ARE HEREBY REQUESTED TO INSPECT AND ISSUE CERTIFICATES FOR THE FOLLOWING ELECTRICAL EQUIPMENT TO BE INSTALLED SY THE UNDERSIGNED TEMP. N DATE CCAIMTY ,� TCNYNSFtlP r � CITY OR VILLAGE c. POLE NUMBER :i rfiEEx AND NO ELOOK LCir SECTION BETWEEN WHAT TWO CROSS STREETS IS PREMISES LOCA 'W- r �'- ✓.'- f' • �r .R, r' - i- BUILDING OC:CURMICY OCCUPA rs NAME -' ,.�„,[• ! i I - !•'�_ 1" . - • . �.e .: r , ..�' '�~ +J. ✓ _ HOME TELEPHONE NUMBER pWHER'S WAI.1E AND ADDRESS Tr �/' , ,„. �' 3, ( ! - '�'+.T- OFFICE YJORk'fEI..EP(IONE NUMBER J FROM THEIR CURRENT SUPPLIED Uy /,/�� /'� . B L,n~ BUILDING IS T pOy�T DEFECTS' REMOVED OLD � WORK IS NEO� L4ST BELOW ALL Ef]UIPMENT WHICH YOU IN ALLEBBRANCH 'OFFICE USE NUMBER OF OUTLETS No. of Fixtures R MOTORS HEATERS CIRCUITS . . ONLY Ica- LnmP Receplacles H_c N waft. NG. Gam INSPECTION Side Attch a 'x SWIIch paw rsc BKB1 No. Type Each D Ea'CIT Ceiling wall flelcep'IS OUT- SIDE SUB- BASE SASE• _ .. MENT / ur 15T 4? FL. Vnd FL. 3rd FL. REMARKS: LIST OTHER 'ELECTRICAL DEVICES NOT BET FORTH ABOVE. THIS APPLICATION 1S INTENDED TL"1 COVER THE ABOVE-LISTED EQUIPMENT TO BE INSPECTED. BUT 1F AT TIME OF SNT THE ON, THERE I FOUND APPLADDIICATION I EQUIPMENT NOT ABOVE LISTED, YOU ' AUTHORIZED TO MAKE THE INSPECTION AND ADJUST THE FEE TO CDVER THE ADDITIONAL EQUIPMENT AS PROVIDED BY THE APPLICANT. TOTAL (Naas FEEDERS EI..ECtFTIG SION&4.Al,IPS SIZE OF WJNS i _J "PCISF.D GAS TUDE SIGryITgAN SI-ORMERS OF CRARACT,A OF WORK CONCEALED r.A/'AICrI'✓ p{p'E 0DUPLFTED SUE OF SIGN(NUMBER) DaE WpITK TO BE slxaTrED i'w . 4F . x MANUFACrI1RER 4F SIGN SEFMCE ENTERS BUILDING ftr UNDERGRODNO Q OWRHEAD >•q,Rt R�+.*'r*�'T��^1.S �� y{ 3 1]Ax€ INSPECTION RIE{RUE".ixED!}N 61:1 AS NEAR AS POSS110LEj .; I, F �.'•..• 1 �• � ' "' ` . PRINT NAME AND ADDRESS DAJ'E OF APPLICPnON .. NAME C N7 ,r' ' APP fAP TEL£AHONE Ntl STREET AODFiEsS _. !7� ZIP CODE o, f - LICENSE Nib. WHEN APPLICABLE I CITY OR POST OFFICE /",. .mac' 6- 4. / � ' S r Q 202 Arterial Road ❑ 85 John Street ❑ 41 State Street ❑ 570 Delaware Avenue ❑ 217 Lake Aarenue NEW YOR1 NY 10038 A State NY 12207 6UFFALO, NY 142021 ROCHESTER, NY 14MS SYRACUSE. NY 13206 THE NEW YORK BOARD OF FIRE UNDERWRITERS TOWN OF QUE04W:: Adm Poo do jai/aw- _ e 1p Sig, t ► �► Alt ---- - kd is ii ITO