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1989-881 A p CERTIFICATE OF OCCUPAMCY TOWN OF QUEENSSMY WARREN COUNTY, NEW YORK Yu pate January 16 19 90 is Rsto ccrtify that work requested to be done as shown by Permit No. has been completed. This structure may be occup" as a Deck A Addition Location IS Bonner Drive Owner KEN A MARY CQLLYER By Order Town Board TOWN OF QUEENSBURY Director of Bldg. & Code Enforcement r BUILDING PERMIT 1K TOWN OF CCU EENSBURY No. WARREN COUNTY, NEW YORK PERMISSION is hereby granted to KEN A MARY C011YER OWNER of property located at 15 Banner Dri vP Street, Road or Ave. .F in the Town of Oueensbury, To Construct or place a deck and addition 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 Oueensbury Building and Zoning Ordinance. 1 . OWNER'S Address is n 0 r- 2. CONTRACTOR or BUILDER 'S Namerrl -rC ALPINE CEDAR HOMES , INC . 3. CONTRACTOR or BUILDER'S Address Y !Z� S+O -+C 4. ARCHITECT'S Name &. ARCHITECT'S Address 679 6. TYPE of Construction — {Please indicate by XI Z 1'I'1 ( XK*ood Frame ( ) Masonry ( I Steel i l d T. PLANS and Specifications C No. 400 sq . ft . of ext . deck and 14 ' x 19 ' addition as per plot plan m application and specifications * $, Proposed Ilse - ' Deck and Addition , cs v $ 56 . 00 PERMIT FEE PAID — THIS PERMIT EXPIRES November 9 19 90 9S (it a longer period is required an application for an extension must be made to the Building and Zoning inspector of the town of Otleensbury before the expiration date.) •� 1�7 m Dated at the Town of 4ueensbury this �I7 Day of }November 1989 e� " SIGNED BY for the Town of Queensbury Building and Zoning I nspector TOWN OF Qum NSBURY REVIEWED BY TpW,ryr Or FEE PAM S F?e ZIVEEQNSQUIq), PERNaT NO, NOV BUILDING PERMrr APPLICATION s 79� COpE 0EPr A PERWr MUST BE OBTAINED BEFORE BEGINNING +CON'STRUL"TION. NO INSPECTIONS WILL BE MADE UNTIL APPLICANT 'HAS 11ECEIYED A VALID BUILDING PERMIT. 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: P .O. Address ,�terr el. ` r,_s.slGlt�ef� �'Z''S4C►t� ,.�, I I �e' PraPertY Location Has there been any split of this property since October 1 , 1988 ? I If yes Planning Board Review is necessary. yes no ` SUBDIVISION NAME, IF APPLICABLE F- ..` � -�C 6 LOT NC1. . ], THE PERSON RESPONSIBLE .FOR, SUPERVISION OF WORK AS REGARD'S TO BUILDING CODES [S: NATURE OF PROPOSED WORK: ESr:MATED MARKET VALUE OF Construction of a new building ,. CONSTRUCTION : S Addition to a building * COMPLETE INFORMATION REQUIRED BELOW* * Size of property ©Cp _ ft x ri ft. Alteration to a building * Existing Buildings( 3 ) Size Z. CP ft. x ft. (no change to exterior dimensions) Proposed building - distance from property line: Other work (Describe) " Front yard ft. Rear yard Om ! j w6ft. Side yards ft. and �-_.n- '� ft. GROSS AREA OF PROPOSED STRUCTURE If on corner, setback from side street ft. 1st Floor sq. ft. . ' 7 ���� ��y�,,� * OCCUPANCY INFORMATION 2nd Floor "' sq. ft. 'Primary Building Other Floors SQ. ft. J.One Family Dwelling (not cellar or basementYwwwwwwwww * Two Family Dwelling TOTAL FLOOR AREA I &C�' :q. ft. • Multiple DweWng/Number of units * Business S[xe of new structure.19L_ft xft. Industrial • Foundatio le lablcrawl/pertial/full circle one) * Other • Now of stories (habitable space)! Height (grade to ridge) 160 ft. » If addition, what will use be± If residential, no. of familieswow • � ,f-J�! Nom of rooms(excluding baths) * AcceAcat T " No. of bedrooms • ory Building No& of bathrooms Detached Garage ONE/TWO Car • Primary heating system1�GI�' '%Ql • Atta►e3hed Garage ONEITWO Car Type of fuel �„� ' Private storage building Now of fireplaces to be installed ' * Other Will a woad stove be installed Central Air conditioning O V* ER BUILD [NG PERMIT APPLiCATrON C0 4TINUED BUILDING 3PEC' IFiCATIONS: T} pe of construction, wood frame, fire safe, etc. W r Will any second-hand or upgraded iismherbe used ? If so. for what ? "A= Foundation wall material -- Thickness -� Depth of foundation below grade (to bottom of footing) l Will there be a cellar ?'Heated or unheated? Floor sq. footage sq --� ft . Will there be a basement ?.Will any portion be used as living space ? (if so, what portion ? --- sq ft. Type of use? .. Type of roof -OEE flat/shed/other 'Material of roof Size, wood studs 40f- _" spacing?" o. c. length.0 _ft. Air* C,.�k �} 1 Joists (floor beams) 1st floor ' "x� " ;pacing c& "o.c. span , A ft. Joist (floor beams) 2nd floor "x ... " spacing — Tro.c. span ft. Overlays (ceiling beams) aa "xl " spacing " o. c. span� ft. �ArQ" ,A�sy4Crr'© Roof rafters x_ _ * spacincrlo4 k==J span ft,3�,, 4 4.,[y` •4 r�ir� iQ1 -� Roof trusses (pre-engineered) spacing "" " O. C. span -- ft. Exterior wall finish _ NA& ,, !TZ1121 tt�" of what material? '�cl�_�Z.r-t► /' , Interior wall finish sc c' � 2 A/,& it y ,, It:;>, r n,.ir. If a garage is to be attached, describe materials to be used for FIRE SEPARATION: % Is 'there to he an opening between garage and dwelling ? If so will a Fire-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�'-t r' L_ADDRESSA4 ..1j XgaeVtj 'lr L.. '<'� TEL. NO. �T `�-I' 6ro4s NAME OF PLUMBER ADDRESS --- TEL. NO. NAME OF MASON it t r ADDRESS TEL. NO . NAME OF ELECTRICIAN fir ADDRESS / 0 r TEL. N04 f DEC LA RATION 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 clone on the described premises and that all provisions Dip at4n - RUILD[NG CODE, THE ZONING ORDINANCE, and all other laws pertaining to the prapa &d work shall be complied with* whether specified or not, and that such work is authorized by the owner. Signature f!` . !�5 G' Ho • co> . Owner, own s went, architect, contractor SPECIAL CONDITIONS OF THE PERMIT: BY TOWN OF QUE NSSUA : WARREN COUNTY , NEW YCRK 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 : I . Gross floor area 2 , Type of heat 3o is the building mechanically cooled ? / 4 . Percentage of area of windows and doors oZ, , [ A . over 16 % Only I . U value of gross area of walls , roof / ceiling and floors exposed to ambient conditions 'Vr,f' dA.Cm 2 . Floor over heat . . 3 spaces YES No a . Are foundat on walls insulated ? YES N I . If YES . what is the R value ? [� 3 , Slab on grade YES o ' a . If YES , wh _ t is the R value of insulation around perimeter of floor ? 4 * a basement heated ? YES g a , � . R value of insulation 5 . Type of insulation W=2 Aa.Lg.,A � t Be 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 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 C . Controls .,. 1 . Thermostat maximum heat setting D . Duct Systems 1 . Is duct system installed in unheated spaces ? YES NO a . if YES . R value of duct installation be R value of duct in other areas E . Piping Insulation 1 . Size of hot water or' dooling 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 . :ZG tf;) ' 1��._. ( applicant ' s sig tore } Aw4 N r. TOWN OF QUEENSBURY � BUILDING AND CODES DEPARTMENT BAY & HAVILAND ROADS M C)UEEN,S'BURYs NEW YORK 22804. i TELEPHONE (528) 792-58.32 BUILDING INSPECTOR ' S REPORT RBQUES3I�FOR IN5P8CT1,QN RECEI NAME VEb 4'Z l lf � LOCATION} ,--_ DATE _ f -- — APPROVED FOOTINGfPIERS YES NO MONOLITHIC POUR i S F QUNDATIQNfDAIyp_PR PING BACfCFILL APPROVAL ROUGH PLUMBING FRAMING ELECTRICAL ROUGH-IN INSV LA TION; FOUNDATION FLOORS WALLS CEILING LAP rNA4 INSPECTION r l CHTMAIRY HEIGHT ROOFING S.rDSNG EXTERNAL PORCH T PS STAIRS-CLEARANCE & PLUMBING PX4Y RESfR EF INTERIOR TRIM/PRIrVA VAL[�L DOORS FIN-TSHED FLOORSGARAGE FIREPROL]FI DOOR CLOSER (S) SAIOICE DETECTORS FINAL ELECTRICAL F NSPEC7 FINAL APPROVAL CONSTR TTON A SIGNED CER OBTAINED IFICATE OF ~- ---.__ F THE BUI Lb,�NG ryUPANCY MUST BE THESE PREM ES ARE EPAR7MENT' BEFORE OCCUPIED REMARKS: ( a = rn INS ECTOR �y TOWN OF QUEENSBURY BUILDING AND CODES DEPARTMENT ,. / RAY 6 HAVILAND ROADS �%J QUEENSBURY, NEW YORK 1280+R TELEPHONE ( 528) 792-5832 BUILDINC, INSPECTOR ' S REPORT f REQUEST F INSPEC' ON REC RXVFDl 4 /90 NAME f -` LOCATSON DATE d PERMTT # / APPROVED FOOTING/PT YES NO RS MONOLITHIC POUR FORMS FOUNDATION AMP-RRODFTIVG BAC'KFILL AP RCYVA ROUGH PLUMB G FRAMING ELECTRICAL R UGH-IN IIySULATION: FOUNDATION FLOORS WALLS �+ CETLING !°".FINAL TNSPRCTX CHIMNEY HEIGH ROOFING SIDING EXTERNAL PORCHE /STEPS STASRS-CLEARANC & RAI PLUMBING FIXTURE RELIE VALVE TNTERrOR TRIM/PRI ACy IqS -- FINISHED FLOORS GARAGE FIREP,RO£)FIN DOOR CLOSER (S)SMOKE DETECTORS DETECTORS FINAL ELECTRICAL INSPEL ION — PrIVAL APPROVAL OF CONS TTON � . A SIGNED CERTIFICATE OBTATNED FROM THE BUI TNG EPACY MV S .9BE TFIE`SE PREMrSES ARE OC UPTED! EFORE REMARKS: /V, rNSPEc o,� �. ...•..-�'vv-anti.. v � MIDDLE DEPARTMEN T tNSAECTtON AGENCY, INC,9GU ii!!rldc+n Aironua }Co'Illrlgawpord:H.J. O8t48 . f oa.w December 30 , 1.989 ' frt[ fCeB that thet eectriCal equipment fisted has been examined and fs a with the National' Electrical Code; applicable governmental, utility and Agency pprc�ved as being in accord Owner; Mary P Co Z Iyer 9 cy rules. ;�. .. oCC11pciR1: Same CJCGUpaRCy: a Location: 15 Bonner Drives Queensbjsr War' Dwelling G J' ~ zen Co) • PlY Equipment: �- l Clu t Le is �' 5 Aerve. r tac l es aaire clfra Gaa+t Onaf egwpmenfcirigai eghrpment ana instafiatran ins Recrea this I , 2 Fixtures exrshng sys^em tn� ahouW be rntroducea or s certnc�ate andra pplg rnatle ; spect i on sh o ura be su b m 1 Hid ArpmPH� Whit and vnrd, and applfCB114A for I/S+-y�J •.A HC1ger p'f [hrs CeFIMCOfe snpijtq F y la let njSge property Of cOh,Ran Yf as ivedinae parse ni Sa rna 01 he trical Yy 'nsuran Ce Carrier as specrflea ?�'perttliCOhon p3 ilectndai equipment approved `,. h C r Bob Murtha Inc C 7 Applicant: ;, q� 91 Mann i s Road _ Queensbur3' # iYY 1. 28{]4' -_ ` 4 — No . 15 -031-426 Form Nn. 'M EL 1-83 I TOWN OF QUEENSBURY BUILDING AND CODES DEPARTMENT .BAY & HAVSLAND ROADS QUEENSBURY, NEW YORK 1280!& TELEPHONE (528) 7.92-5832 BUIMING INSPEC"TOR ' S REPORT REQUEST roR INSPECTION REC,ErVQED NAME LOCATION DATS APPROVED YES NO FOOTING/PIERS MONOLITHIC POUR ORMS FOUMZATSON/DAMP— ROOFXNG BACKF XLL APPROVA ROUGH PLUMBING ; FRAMING ELECTRICAL ROUGH— INSULATION: FOUNDATZON FLOORS WALLS CEILING FINAL INSPECTION: CHIMNEY HEIGHT ROOFING SXDING EXTERNAL PORCH /STE S STAIRS—CL.EARAN & LS PLUMBING FXXTU ES/REL EF VALVE INTERIOR TRIM RXVACY DOORS FINISHED FLOO S GARAGE FIREPR FING DOOR CLOSER ( SMOKE DETEC RS .FINAL ELECTRZC L INSPECTX N FINAL. APPROVA OF CONSTRU ION A SIGNED CER FXCATE OF OCC NCY MUST BE OBTAINED FROM THE BUILDING DEFARTMENT BEFORE THESE PREMISES ARE OCCUPIED! REMARKS: al p _ Lu INSP TOR TOWN OF QUEENSBURY BUILDING AND CODES DEPARTMENT BAY & HAVILAND ROADS QUEENSBURY, NEW YORK I2BO& TELEPHONE (518) 792-5832 BUILDING INSPECTOR ' S REPORT REQUEST FOR SPECTION RECEIVED NAME ( 3 L J� LOCATION I C ; A /v6y YZ DATE i PERMIT ( - APPROVED YES NO FOOTINCIPIERS MONOLITHIC POUR FO S FOUIVDATSON/DAMP-PR FING BACKFIL.L APPROVAL ROUGH PLUMBING �MING ELECTRICAL ROUGH-IN X-rNSULATION: FOUNDATION FLOORS WALLS i.L iD 4 FINAL INSPECTION: CHIMNEY HEIGHT ROOFING SIDING EXTERNAL PORCHES/STE S STAIRS-CLEARANCE & 2 PLUMBING FIXTURES,/R LSEI VALVE INTERIOR TRIM/PRIVA Y DORS FINISHED FLOORS GARAGE FIREPROOFING i DOOR CLOSER (S) SMOKE DETECTORS FINAL ELECTRICAL IN.S ECT.TON FINAL APPROVAL OF CO STRUCTI A .SIGNED CERTIF.XCAT OF OCCUPA CY MUST BE OBTAINED FROM THE B 2LDING DEP TMENT BEFORE THESE PREMISES ARE CCUPIEDI' REMARKS. dL Z�?� a � r INSP,�CTQR TOWN OF QUEENSBURY , /J BUTLDTNG AND CODES DEPARTMENT BAY & HAVTLAND ROADS �F QUEENS.BURY, NEW YOR,K I280&L TELEPHONE (538) 792 5832 BUILDING SPECTOR' S REPORT REQUEST FOR INSPEC ON RECEIVED NAME A LOCATION J1- DATE PERMIT #_�s APPROVED YES NO FOOTTNGIPIERS NONOLITHTC POUR FO S FOUNDATXON/DAMP—PR FING BACKFILL APPROVAL OUCH PLUMBING RAMING ELECTRICAL, ROUGH_ TNSULATTONr FOUNDATTON FLOORS WALLS CEILINGt- FTNAZ INSPECTION: CHIMNEY HEIGHT ROOFING SIDING EXTERNAL PORCHES' TEPS STAIRS—C.LEARANPE RAILS PLUMBING FTXTreRE RELIEF VALVE TNTERIOR TRIM(ZRT ACy DOORS FINISHED F RS GARAGE FIREP OOFS G - DOOR CLOSER S) SMOKE DETE RS FINAL ELECTR CAL IN ECTTON FINAL APPRO L OF C STRUCTION A SIGNED C RTIFICATE OF OCCUPANCY MUST BE OBTAINED ROM THE BU LDING DEPARTMENT BEFORE THESE PR ISES ARE CUPTED! REMARKS: �f I J(,1.5 L.1� f 4 � !" G�Jf .' `✓ �i.''�,r.- 1C �r;?- i+L?�� INSP TOR 4dational Headquar-�ers s n - Ke �..Colddddlingsinrcx ' IJI _ f C.tlyTnt@n tlh TpM�lShip h k t Goirrity Flf Located in Renal Area - plea" dP ?t — _Sutate OvXner ' ti.. At#ac ❑IreC#IonS� a . {... E OCCUI _. Winn Ser B , (] uild ngrd NeW Nud JOAO itt,e+d ors: �` , Wo XC ,4rea Fn Buildln Floor cr# etc �. ld [] Cash r l : Rea f r lrr { rtnQf Elect . € ; . aQ 1 M.O. f r Cora:: Lighting , 15 1�ao rao xzBo ssco arao IYfSkE Pa` a .: -'_ aoao tacles - --- - Ainp. erv�ce _ �"�.; u� t- �, r pw` urn * --- --�• Neater - -��AFr =dUinF DOiagtiwbs�terYr.-. . ._ d._.._,a__ y ., CaR . boner :�--�i -� � an * ieeeptaCie �C3a .ge- }1ffR�al Wiring and Controls for l�unrtp ,• Cher OulAine �--=�:_Ptmtional H.P. Vent Fart -�-- Burners . Merle 1Vumber 1!e 1Id of Each sine 1!4 3fa ." 1 lay 2 signature •y ; `3, 4A .. '� -.�`S 1q7 - ?/A ^ t lid APPI did ant's Aq �-+canes 0 < sr : (City) �l .i� dr sa "" #y .. _ - " K t {: ''Ise INTO Re t 1. 21 otica I . -l..alle I�}Ou 11VFring Uutle2s r€ . Swrtches S"idfaoPi! UnId. y Rem cles 1;an ''y � ,.; ' Fixtures r eater Amp. service Eq., Alr Con4itiorae spektal pment y tiv her Am . Service Conductors Burner 4Viri+f9 8e Con#role' fpr D P wt]TORs H.P '.. 1/pe 1lark Number r✓la s rs r lilt IPn^I l?yrr� !+r sy3 _s A �• eca#i if Each size R tacle�` .. a : - �•;. _� . '�'.._ , 5� . 7ih• 33 :: Eieat. H eao Tao 1 eat oao ssso laoo 1�5o Qogo ,azao 3soo -sr P. .. r- - A S. _#'rragr CJ ViofatFon: Work COrI'!p Y �1 " ice ]r.iI w i �_. R,. ee �..(l"y�y,p CHIC i4E" } j _ ' "Y'LING did, rM id NV p -. . rr Cr# a + Clt4Y '. Terri " ., .. .t. j's +1t9d �Clwner ij s may# v 4 : D CATRt k _ A 1 . . TOWN OF OUEENSBURY BU'SLDING AND CODES ,DEPARTMENT BAY & HAVILAND ROADS [�1 0QUEENSBURY� NEW YORIC - 280� `C,}1 2'6LE'PHGINE (518) 792-5832 1 D Z � BUILDING INSPECTOR ' S REPORT 16112 :3 1 RIVUEST FOR .INSPECTION RECESVEb NAME /~ i LOCATION DAT$ <y L "PROVED 1'NG/PEE' R ND MONOLITHIC H FORMS FC7i7NDAT rC7N/D -PRC�DF�NG BACKFILL AX'i°ROt(AL ROUGH PLUMBSNG ' FRAMING ELECTRICAL ROUGH ly I4mSi*1 TIONZ +FOUNDATION FLOORS WALLS CESLING FI NA L SNSPECTION: CHIMNEY HEIGHT ROOFING SSiJ.I'NG ExTERNAL PORCHES/ EPS STAIR -CARANCE Lr-- PLUMBING Fxx2vR RA XNTERIOR f /RELIEF TRIM P SVACY DOO FINISH$D FLOOR GARAGE FIREPR FIND DOOR CLOSERS SMOKE' DETECTO S FINAL 'EL'ECTRSC .rNSPECTION FINAL APPROVAL OF COn''S2rRUC2'ION A SIGNED CERTS SCATE OF OCCUPANCY MUS' Be OBTAXIVED FROM H$T BUILDING DEP HESE PREMSSES ARE AR27MENT BEFORE OCCUPIED!• REMARKS: CMI - , .. SNSPECToll? THE NEW YORK BOARD OF FIRE UNDERWRITERS CERTIFICATE NO DO NOT WRITE HERE - FOR OFFICE USE ONLY BUILDING PERMIT NO. TEMP M DATE { � E CITY OR VILLAGE TOWNSHIP \ GOU NTV STREET AND NO OR ROAD �^- POLE NUMBER BETWEEN WHAT TV40 GROSS STREETS IS PREMISES ED? SECTION BLOCK LOT % wy- OCCUPANT S NAME BUILDING OCCUPANCY lL .y. I br;G. _� OWNER'S NAME AND ADDRESS HOME TELEPHONE NUMBER 4 CURRENT SUPPLIED BY FROM THEIR OFFICE ...� 9 RK TELE PHONE NUMBER BUILDING ISl/� p".�{ NEw At ` , x I OLD ❑ WORK IS NEW I.I ADDITIONAL DEFECTS HE L. LIST BELOW ALL EQUIPMENT WHICH YOU INSTALLED NUMBER OF OUTLETS No. of Fixtures & BRANCH OFFICE USE Lea- Lamp Receptacles MpI"Oi�S HEATERS CIRCUITS ONLY tion Side Attaeh't H.P Watts AWG. Ceiling Wall Recep'Is Switch Pendant Bracket No- Type Each NO. Each N°. Gauge INSPECTION OUT- SIDE SUB- BASE BASE MENT 1st FL. _ 2nd FL. 3rd FL. REMARKS: LIST OTHER ELECTRICAL DEVICES NOT SET FORTH ABOVE. THIS APPLICATION IS INTENDED TO COVER THE ABOVE-LISTED 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. SIZE OF MAINS FEEDERS ELECTRIC SIGNSlLAMP$ TOTAL WATTS CHARACTER OE WORK U EXPOSED GAS TUBE SIDNfTRAN SFORME RS OF VA CONCEALEO DATE WORK TO BE SL ED 0ATE COMPLETED SIZE OF SIGN (NUMBER) !'APIC:ITY 1 [ r t r- 17 e-,il SERVICE ENTERS$UILDING E �� r—I MANUFACTURR OF SIGN El OVERHEAD 1 J UNDERGROUND DATE INSPECTION REQUESTED ON(OR AS NEAR AS POSSIBLE I y MUST ENTER APPLICANTS IDENTIFfIrATION NUMBER { [ "DID DELAYS BY GIVING FULL AND ACCURATE INFORMATIDN_ ALL SPACES MUST BE FILLED IN oR APPLICATION MAY BE RETURNED. PRINT NAME AND ADDRESS NAME OF APPLICANT / DATE OF APPLICATION /SIGNATURE OF AP STREET ADDRESS TELEPHONE CITY OR POST OFFICE - ZIP CODE LICENSE NO, WHEN APPLICABLE c `� 85 John Street 41 State Street C] 570 Delaware Avenue I l 217 Lake Avenue L� 202 Arterial Road NEW YORK, NY 10038 ALBANY, NY 122D7 BUFFALO, NY 142021 ROCHESTER, NY 146081 SYRACUSE, NY 13206 THE NEW YORK BOARD OF FIRE .UNDERWRITERS DIETZGEN MASTER FORM 198MF