1989-902 } f
1
CERTIFICATE OF OCCUPANCY
TOWN OF QUEENSSURY
WARREN COUNTY, NEW YORK
' l
C June 14 l9 90
DateThis is to certify that work n.requested to be done as show by Permit No. $ - 2
j has been completed.
This structure may be occupied as a
Single Family Dwelling
Location �� Whi 5 p e r i n a Pines Way
li der Douglas $urbridge -
1
By Order Town Board
l 'TOWN OF QUEENS$URY
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[ Director of Bldg. & Code En rcement
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i
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I
BUILDING PERMIT F
TOWN OF QUEENSBURY No. 89-902
WARREN COUNTY, NEW YORK
ro
PERMISSION is hereby granted to DOUGLAS SURBRIDGE r+�
t2t
.s*
OWNER of property located at Lot 55 - Whi S 3�eri i1q Pines WaY _ Street. Road or Ave.
in the Town of Queensbury. To Construct or place a Si 1 e Fare ' 1 Dwel i n
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.
[4. ARCHITECTOS
NER'S Address is tX•
22 Cedarwood 'Drive a
Ballston Lake , NY 12019
NTRACTOR or BUILDER 'S Name C+ l
r
G
Self
as
NTRACTOR or BUILDER S Address
Vt
NameOCHITECT'S Address
67'1
w
6. TYPE of Construction — (Please indicate by X) N
-v
r+n
( XD(YVood Frame { I Masonry { ) Steel
7C
7. PLANS and Specifications
No. 76 ' x 28 ' single family dwelling with septic system and attached rn
two car garage as per applications specifications and plot plan . r
S. Proposed Use
Single Family Dwelling
$ 293 PERMIT FEE PAID — THIS PERMIT EXPIRES July 17 19_ 9D a
(if a longer period is required an application for an extension must be made to the Building and Zoning Inspector of the rn
town of oueensbury before the expiration elate.)
"n
Dated at the Town of Queensbury this 17th Day of January l9 90
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SIGNED BY for the Town of Oueensbury
Building and Z4 no 1 nspector r
r—
o-.�
z
a7
TOWN OF QUEEMSBURY
REVrEwED BY TOWN OF QUEEN SSURY
---ems- FEE PAM $ {/ RECEIVED
•• PERNarr NO. . _ � `
NOV 11- 1989
BUILDING PERMIT APPLICATION
BLQQ, & CODE DEPT.
A PERIff MUST BE OBTAINED 'BEFORE BEGINNING CONSTRUCTION. NO INSPECTIONS
WILL HE MADE UNwM APPLICANT HAS RECEIVED A VALM 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.
# # * # # # # # ! # # # # # # # # # # * # # • # # # # # # # # all # # # # # ■ # # #
The owner of this property is: �-'
P.O. Address Gti Z '.rx.3€�c�ea 1 ,� Lc i n r . t ' IY�t orr Tel
Property Location 5-� Wlejs� : `"` ' `'� Tax Map No. /yl
Has there been any split of this property since October 1 , 1988 ? /
If yes Planning Board Review is necessarys yes no
SUBDIVISION NAME, IF APPLICABLE / YAI r04, lelovr.�> LOT NO. 5�S
THE PERSO?f RESPONSIBLE FOR SUPERVISION OF WORK AS REGARDS TO BUILDING CODES IS:
NATURE OF PROPOSED WORK: » Esr*,MATED MARKET VALUE OF
Construction of a new building , CONSTRUCTION: $
Addition to a building " COMPLETE INFORMATION REQUIRED BELOW:
* Size of property 1140 ft x �ft.
Alteration to a building * Existing Buildings( 3 ) Sizeft. x
(no change to exterior dimensions)
Proposed building - distance from property line;
Other work (Describe) w Front yard ft. Rear yard I Z-' f't-
Side yards ''f' ft. and Z q ft.
GROSS AREA OF PROPOSED STRUCTURE * If on corner, setback from side street ft.
1st Floor -Z/� sq. ft. J &6 OCCUPANCY INFORMATION
2nd Floor � T sq. ft. �� r Primary Building -
Other Floors -�' sq. ft. n° Family Dwelling
(not cellar or ement • Two Family Dwelling
0 I ft. " Multiple Dwelling/Number of units
TOTAL FLOOR AREAI sq.
Sias of new structure i "` ft x 7"'F ft. " Business
Foundationl$or/slab/crawl/part full ) " Industrial
(circle one) Other
e
Na. of :torus. (habitable space) -. ._..,....
Height (grade to ridge) Z ft. * If addition, what will use be?
If residential. no* of familisa 1
No* of rooms(excluding broths) Accessory Building
No. of bedrooms "` Detached Garage ONE/TWO Car
No* of bathrooms �- f •
Primary heating system ors 60 /i-r.2- • Attached Gauragr O ITWO C+ae
Type of fuel 0 E ✓ " Private storage building
Now of fireplaces to be installed ,. Other
e
Will a woad stove beirtatalied 1...r
Central Air conditioning ) k9_ 011O ER
a
BUILDING PERlIIT APPLICA710N CO VTrVL: ED -
BI: ILD [VG APFC' IFIC ATIO %NTS:
Type of construction, woos! frame, fire safe. etc. UtJZ>Q � F0W_ }-r1 C.--
Will any second-nand or upgraded Itimherbe used ? If so, for what "
Foundation wall Material _Thickness /U rf
Depth of foundation below grade (to bottom of footing) V �
Will there be a cellar ? �F{ eated or unheated? - Floor sq. footage -- ,q ft .
Will there be a basement ? '4" Will any portiori be used as living space ? A,)
(If so, what d/portion ?
-��— sq ft . Type of use ?
sl --
Type of roof o at/shed/other. Nlaterial of roof
Size, wood studs . 11x IF spacing" O.C. length ft .
Joists (floor beams) 1st floor 2. "XLee? -pacing _01o. c. span Pt.
Joist (floor beams) 2nd floor 11x _ /0 " Spacing 46? o. c. span ft.
Overlays (ceiling beams )_"x " spacing " o. c. span ft.
Roof rafters �'*x " spacing, o0c. span ft.
Roof trusses (pre-engineered) spacing 2.Vt - ' o. c, span 4�v, ft.
Exterior wall finish f 7"c Ac , of what material? CAF• I;X-�'� -- -
f
Interior wail finish —� lRj�
If a garage is to be attaached, describ{e� materials to be used for FIRE SEPARATION:
Is there to he an opening between garage and dwellin
self-closing device be provided? r g' " If so will a Fire-rated door, enclosure,
Will a flue-lined chimney be installed? AJO Height above roof
ft .
Depth of chimney foundation below grade
Depth of fireplace hearth
Water supply - Municipal or private well
SEPTIC SYSTEM Distance from ANY private well (including adjoining properties P ' � `ft.
(A separate application is necessary for any repair or new installation of septic system )
NAME OF BUILDER i trLC rrrs�, A 694 4ADDRESS 22 6+ 4171r ." vn /kTEL. NCT. _---
NAME OF PLUMBER, err�4GFry U � i7�4ADDRESS ✓T__----- TEL. NO. 5%- �'__--•-
NAME OF MASON_Jptw,,, ��/teoU�P_ADDRESS 4-," ' - _- TEI., N(7. jY! '? - -"
NAME OF ELECTRICIAN '
' e . ADDRESS .. . E7L f . Sq ?r TEL. NO. /`' .ZiF
DEC LA R,AIMON
To the best of my knOwledge and belie!' the statements contained in this application, together with the
plan and specifications submitted, are a true and complete statement of all propeased work to be done on
the described premises and that all provisions of the BUILDING CODE, THE PC PCsZONIN
UfRAINAbe do and
aL other laws pertaining to the proposed work shall be comp ied with, whet r
such work is authorized by the owner. s P*Cifled or not, and that
Sigruature Z/
Owni r, owner's nt, architect, contractor
SPECLAL CONDMON3 OF THE PERMIT:
BY
TOWN OF QUE , NSBURc / �-
WARREN CO {JNTY , NEW YORK rOWN OF C,RECE1
Application for : BUILDING PERMIT IN COMPLIANCE WITH THE NEW PORK J
STATE ENERGY CONSERVATION CODE RN
A permit must be obtained before beginning work .
BLDG. & CODE DEA
ANSWER ALL of the following :
1 . Gross floor area � �
2 . Type of heat
3 . Is the building mechanically cooled ? �'
4w percentage of area of windows and doors
A . over 16 % only
mmmmmm
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 an walls insulated YES NO
1 . if YES , what is the R val ?
3 . Slab on grade YES No
a . If YES , wh . t is the R Val f ulation around
perimeter of floor ?
4 . Is basement heated ? YES NO
a . R value of insulation
5 . Type of insulation
s . 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 3
4 . R value of doors p-
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
B . R value of heated basement/ cellar walls ( above grade ) //
9 . R value of heated basement/ cellar walls ( below grade )
f
100 Type of insulation
C . Controlsmmmmmw
"
1 . Thermostat maximum heat setting
U . Duct Systems
mmmmmm
10 is duct system installed in unheated spaces7 YES
a . if YES . R value of duct installation
b . R value of duct in other areas
E . Pipping Insulation
16 Size of hot water or cooling carrying agent pipe -/ [�' .
2 . R value of pipe insulation
F . Service Water Heatin c �
1 . Performance efficiency 000
� `1ri
2 . Temperature control setting maximum ., ,,._. .r..
G . For Swimming Pool OnIY
1 . maximum heating
Telephone No . >�l I Y71 "j
( a licant ' s i nature )
TOWN 0F .QLJ1 ENSBUPZY
APPLICATION FOR
SiEPMC DISPOSAL 'PERMIT
DATE
LOCATION OF PROPERTY FOR INSTALLATION SS �^�'�iSd°.�a r. k, ✓��X fig' 46
Owner's Name@ ))oy,4 A-S T
elephone:
Address: AZ, `- C7.4fLW�o�' JI �L STD +` h A rsc /t J % J / r
Installer's Name: 6!P. oL " Atc- Telephone:
Number of bedrooms (residential only) f
Total daily flow (compute (d 150 gal per bedroom)
Topography: Circle one(]Flat Rolling Steep Slope % of Slope
Soil Nature: Circle on Sand Loam Clay Other /Depth: Feet
Ground Water: At what depth? jc>Afje . Feet
Bedrock or Impervious Material: At what depth? L-JD s-,f 0': --'Fe e t
Percolation test: Circle one: not re uired equired rate min. inch.
Domestic water supply: circle one:CNIunicipal Well Other
If domestic water supply is a well:
Separation: Water supply from septic absorption � feet
PROPOSED SYSTEM* Septic Tank gal. ( minimum size: 1 gal. )
TILE FIELD : Each Trench feet/Total system length \may feet
SEEPAGE PIT(S): 'Number of Size each
r�
Size of stone to be used 01-- IDepth or Thickness feet
I have read the regulation on the reverse side of this sheet and agre to abide by these
and all requirements of the Town of Queensbury . nit Se ge posal Ordinance,
SIGNATURE OF RESPONSIBLE PERSON: 0
DATE:
OVER
j
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
So ) size and dimensions of all tankse 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
b> submitted to the Queensbury Building Department before further
construction .
Town of Queensbury
BUILDING and CODES DEPARTMENT
Bay and Haviland Roads
Queensbury , New York 12804
R�nA:s r k s :
MIDDLE DEPARTMENT INSPECTION AGENCY, INC. /
800 �: ICatNnp�ehrodM��ll+le'R�tOe � � _ � [✓��
Y cater August 1 , 1990
( Cert[f IP'O that thWelectrical equipment listed has been examined a60. is approved as being in accord
with the National Electrical C946, applicable governmental, utility and Agency' les.
Owner: Doug Burbr i dge " i7CCupegCy: ISterCl l,ig
Occupant: Same
:? Location: To t rj b Wh i spe r i ng•^ • P i ne s r Qeeenee'bu ry Tm( W4JEeS4h0o,rs Q"4<;ira%quipmont and installation inspected this
dare. It addWonal equipment shgyRd be imroduoep w aiteral4ons made to
existing ayatem ihi# iG g ale a17�Y be null and void, sort epp4icahon for
EquiprTRant: 11p- Qixt lets ; 45 - Receptaclt6 ; 3 - FiX p ul d be subetrtted prtatOpt ty td true Apancy.
PYdYIS�# 90 certihca.7a should of same to hi prepeny in zu rance carrier
200 Amp S%'vice ; 5 -Appliances ; x3 -Veflit uki- laaeri ync@ ertilirucm ul aiectricai equ ipmen I app roved
W7 - as spe00
F ERA Elect r
zp Applicant: Candleberry ];tom.
a S2ueensbury , IVY2 - _ 16 - 034032/031
TOWN OF QUEENS.BURY ' {l
BUILDING AND CODEC DEPARTMENT i=
BAY & HAVILAND ROADS
QUEENSBURY, NEW YORK I280&
TELEPHONE (5I8) 792-5832
BUILDING INSPECTOR' S REPORT
REQUEST FOR INSPECTION RECEIVED
NAME ■■.. F3 rY� f
LOCATION 10^ I A-f L'S LAB"
DATE qV qt) PERMIT #
APPROVED
YES NO
FOOTING/PIERS
MONOLITHIC POUR FO S
FOUNDATION/DAMP-PR FING
BACKFILL APPROVAL
ROUGH PLUMBING
FRAMING
ELECTRICAL ROUGH-IN
INSULATION:
FOUNDATION
FLOORS
WALLS
CEILING
FINAL INSPECTION: Mt; 2,
CHIMNEY HEIGHT
ROOFING
SIDING
EXTERNAL PQRCHES/STE S
STAIRS-CLEARANCE & ILS
PLUMBING FIXTURES/R IEF VAL + —V
W INTERIOR TRIM/PRIVA DOORS
FINISHED FLOORS
GARAGE FIREPROOFING
DOOR CLOSE
SMOKE SMOKE DETECTORS
FINAL ELECTRICAL INS ECTION
FINAL APPROVAL OF C STRUCTION
OK Td IssUE C/o OR d/C
A SIGNED CERTIFICATE OF OCCUPANCY MUST BE
OBTAINED FROM THE .BUILDING DEPARTMENT BEFORE
THESE PREMISES ARE OCCUPIED!
REMARKS: 7-A6:2Q f`4 0 oL 1300 r�s
ARRIVE
DEPART
IN PECTOR
TOWN OF QUEENSBURY
BUILDING AND CODES DEPARTMENT Pt
BAy & HAVILAND ROADS
QUEENSBuRY, NEW YORK 12809,
TELEPHONE (518 ) 792-5832
BUILDING INSPECTOR' S REPORT Q /L�
REQUEST FOR INSPECTION RECEIVED t1/3 ba ,f`f��J.('L�--
NAME `T 77��
i r
LOCATION
DATE P RMIT # - 0
.APPROVED
YES NO
FOOTING/PIERS
MONOLITHIC POUR FO S_
FOUNDATION/DAMP-PR I _
BAcKFXLL APPROVAL
ROUGH PLUMBING
FRAMING
ELECTRICAL ROUGH-IN
INSULATION.
P`%%,k'OUNDATION
FLOORS
WALLS
CEILING
NAL INSPECTION:
CHIMNEY HEIGHT
ROOFING
SIDING
EXTERNAL PORCHES/STE S 11
STAIRS-CLEARANCE & __......_
PLUMBING FIXTURES/ E VALV
INTERIOR TRIM/PRIV CY RS
FINISHED FLOORS CJ
GARAGE FIREPROOFI G
DOOR CLOSERS)
SMOKE DETECTORS
FINAL ELECTRICAL NSP TION
FINAL APPROVAL O CON TRUCT N �.000P.
OK TO ISSUE C/o R C/ -
A SIGNED CERTI CATE IF OCCU NCY MUST BE
OBTAINED FROM HE BUI , ING DE TMENT BEFORE
THESE PREMISE ARE OCCUPIEDF
REMARKS: 0 YZ- Aj
oov .
A.;,-r- r A.+ Pi-. -cam- Z7spEcN
r per .O�.
ARRIVE
DEPART 3 %a
T TOR
Jvurn o 'Queen3hure�
BUILDING and ZONING DEPARTMENT
Bay and Haviland Road, R.D. 1 Box 98
Queensbury, New York 12801
SEPTIC ISPOSAL SYSTEM NSPECTION
NAME
LOCATION
DATE �/ PERMIT NO. Z .
SOIL TYPE - a . Loam - Clay
percolation Bt Require YES NO
Percolation r to - Min/I ch
TYPE of SYST
Absorption field , tots length 50
Length of each trench Q
Depth of trench s
Size of gravel_
SEEPAGE PITS4N er )
Size- ft, X t,
Gravel size
PIPING : Size Type
Bldg . to tank
Tank to disc . box
Dist. box to field it
Openings sealed? ES NO Partial
LOCATION/SEPARATI S
Foundation to tar► 10 ft.,fir
Foundation to ab rpt ' on _ ft .
Absorption to to lin
Separation of p ' s ft,
LOCATION zCE ^SYS EM ON ROPERTY (circle one)
Front jelear - ft si - Right side -
CC NMEI3
SYSTEM USE APPROVED YES) Q
Bui. di Ins ector
O1/86 and vl
TOWN OF QUEENSBURY �
BUILDING AND CODES DEPARTMENT CC
BAY & HAVILAND ROADS
QUEENSBURY, NEW YORK 22809-
TELEPHONE (518) 792-5832
BUILD INSPECTOR' S REPa
REQUEST F013 INSP CTI N RECEIVED 27
NAME
LOCATION
DATE � PERMIT #
APPROVED
YES I NO
FOOTI /PIE
MONOLITHIC POUR F S
FOUNDATION/DAMP-P PING
BACXFXZL APPROVAL
ROUGH PLUMBING
FRAMING
ELECTRICAL ROUGH-I
(}INSULATION:
FOUNDATION
FLOORS
WALLS
CEILING ~
FINAL INSPECTION:
CHIMNEY HEIGHT
ROOFING
SIDING
EXTERNAL. PORCHES/S PS
STAIRS-CLEARANCE & I _ -
PLUMBING FIXTURES/ EF VALVE
INTERIOR TRIM/PRXVAC DOORS
FINISHED FLOORS -
GARAGE FIREPROOFING
DOOR CLOSER (S)
SMOKE DETECTORS
FINAL ELECTRICAL INS ECT N
FINAL APPROVAL OF C STR TION
OK TO ISSUE C/O OR /C
A SIGNED CERTIFI E OF OC UPANCY MUST BE
OBTAINED FROM THE BUILDING EPARTMENT BEFORE
THESE PREMISES A OCCUPIED
REMARKS:
� 4
F ,t
ARRIVE r --
DEPARL,_,_ 1 _ !
INSPEICTOR
TOWN OF QUEENSBURY Cry
BUILDING AND CODES DEPARTMENT
BAY & HAVILAND ROADS
QUEENSBURYe NEW YORK 2280k-
TELEPHONE (528) 792-5832
BU MING INSPECTOR' S REPORT
REQUESTaA
I SPE ION RECEIVED42 _
NAME
LOCATION
DATE PERMIT #� - 02
APPROVED
YES INO
FOO NG/P ERS
MONOLITHIC POUR RMS
FOUNDAT-TON/DAMP-P OOFING
BACKFILL APPROVAL
DAROUGH PLUMBING
RAMING d
LECTRICAL ROUGH-I
INSULATION:
FOUNDATION
FLOORS
WALLS
CEILING
FINAL INSPECTION:
CHIMNEY HEIGHT
ROOFING
SIDING
EXTERNAL PORCHESISTE
STAIRS'"-CLEARANCE & LS
PLUMBING FIXTURESIRE EF VALVE
INTERIOR TRIM/PRIVA DOORS
FINISHED FLOORS _
GARAGE F�TRE'PROOFIN
DOOR CLOSER (S)
SMOKE DETECTORS
FINAL ELECTRICAL I SPEC N
_ FINAL APPROVAL OF ONSTRU 'TiTON
OK To ISSUE C/o C/C
A SIGNED CERTIF ATE OF MUST BE
OBTAINED FROM T E BUILDIJUPANCY
DEPARTMENT BEFORE
THESE PREMISES RE OCCUPt
REMARK'S:
�Gk #'c7 5 1 -n 3
A 4L
ARRIVE [Y
DEPAR 9 16
INSPECTOR
TOWN OF QUEENSBURY 1914
BUILDING AND CODES DEPARTMENT
.BAY & HAVILAND ROADS
QUEENSBURYr NEW YORK 1280$
TELEPHONE (518) 792-5832
BUILDING INSPECTOR' S REPORT
REQUEST FOR XNSPECTION RECEIVED lcla
NAME
LOCAT ION `
DATE PERMIT # i
APPROVED
YES NO
FOOTING/PIERS
C0Nor.rTHXC POUR ORMS
NDATION/DAMP- OOFING
CKFILL APPROVA
ROUGH PLUMBING
FRAMING
ELECTRICAL ROUGH-
INSULATION-
FOUNDATION
FLOORS
WALLS
CEILING
FINAL INSPECTION:
CHINNEY HEIGHT
ROOFING
SIDING
EXTERNAL PORCHES/ T S
STAIRS-CLEARANCE & ILS
PLUMBING FIXTURE IRE EF VALVE
INTERIOR TRIM/P IVAC DOORS
FINISHED FLOOR
GARAGE FIREPR FIND
DOOR CLOSERS
SMOKE DETECTO S
FINAL ELECTRI L INSPECTS
FINAL APPROVA OF CONSTRU ION
09 TO ISSUE d OR C/C
A SIGNED CERTIFICATE OF OCC ANCY MUST BE
OBTAINED FROM THE BUILDING D PARTMENT BEFORE
THESE PREMISES ARE OCCUPIED!
REMARKS:
ARRIVE q A
DEPART
S SP R
1
f
TOWN OF QUEENSBURY
BUILDING AND CODES DEPARTMENT / y
BAY & HAVILAND ROADS 1�•+
QUEENSSBURY, NEW YORK 1280sr
TELEPHONE (5I8) 792-5832
BUILDING INSPECTOR' S REPO,1R�T
REQUEST Fof INSPECTIO RECE VE L
NAME II
LOCATIO 1
DA TE {� PERMIT
APPROVED
YES so
,OOOT'XNG/PIERS
NOLXTHIC POUR FORMS
FOUNDATXO N/DAMP~PROOF%NG
BACK-FILL APPROVA
ROUGH PLUMBING 5
FRAMING
ELECTRICAZ ROUGH-17N
INSULATION:
FOUNDATION
FLOORS
WALLS
CEILING
FINAL INSPECTION:
CHXMNEY HEIGHT
ROOFING
SIDING
EXTERNAL PORCHES/ EPS
STAIRS--CLEARANCE &)-RAILS
PLUMBING FXXTURE / LIEF VALVE
INTERIOR TRIM/PRIMA Y DOORS
FXNXSHED FLOORS �
GARAGE FXREPROO .XNG
DOOR CLOSER (S) _
SMOKE DETECTORS '
FINAL ELECTRICAL NSPEC 740N
FINAL APPROVAL O CONSTR TION
f
f
1f
1
A SIGNED CERTIFXgATE OF UPANCY MUST BE
OBTAINED FROM Tfff BUILDING DEPARTMENT BEFORE
THESE PREMISES A E OCCUPXE�.
REMARKS: �O JG'/G"
THE CONTRACTOR 13 RESPONSIBL FOR PROVIDING
PROTECTION FROM VREEZING FOR�8 HOURS
FOLLOWING THE P CE.MEEaT OF T CONCRETE
MATERIALS FOR T S PURPOSE ON TE
ARRIVE 1 1 YES NO
r
DEPART ' _
NSPECTOR
YOU ARE HEREBY REQUESTED TO
INSPECT AND ISSUE CERTIFICATES
FOR THE FOLLOWING ELECTRICAL
EQUIPMENT TO BE INSTALLED BY
THE UNDERSIGNED �,^l��'11,]]
TEMP. # DATE f t./ e?
CI
TY OR VILLAD /1 TOWNSHIP ��✓^"C�WNTV
LJAt.. E:'/r✓`Gy ' +�7 .1/'f3.E".IsW '.++...+1
STREET AHp NO OR ROAD `.r ,y ,w' `� �� .e
J .S f f "rSr/" F!f /..d5; f�w'C.rC AL w'o POLE NUMBER
BLS WNAr TWO CROSS STREETS E: PREMISES ❑ f ,..^y / SECTION BLOCK
LOT
f/CCU S NAME
BULL DING OCCUPANCY
OWN "NAME AND ADDRESS � JJ
1.IL. L /� �IDME TELEP E NUMBER }y.
CUR T SUPPLIED BY FROM THEIR
WORK TELE� r NUMBER
J,ram OFFIC {+ ,r fJr+BUILDING IS �Ay ,
NEW DLO WOFIX IS NEW ADDRK)NAL ❑ DEFECTS REMCNED ❑
LIST BELOW ALL E UIPMENT WHICH YOU INSTALLED
NUMBER OF OUTLETS No. of Fixtures & MOTORS HEATERS BRANCH OFFICE USE
lion Lamp Receptacles Side AttachotCIRCUITS ONLY
Ceiling WWI Recep'Fs Swft PerWara Brxkelt Na.
our- T Each N - Ewen Na Gauge INSPECTION
SIDE
SUB-
BASE
BASE-
MENT
tst
zna
FL_ d
3rd
FL.
REMARKS: LIST OTHER ELECTRICAL DEVICES NOT SET FORTH ABOVE
THIS APPLICATION IS INTENDED TO COVE THE ABOVE-LISTED EQUIPMENT 70 BE INSPECTTIED, BUT OF 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 OFMMNS FEEDERS ELE[;TRIC SIGNSA.AMPS .TOTAL Wll'7S
fl. r _
CHARACTER OF WORK Cf XPOSED SIGWTRAN CRIAERSOF
❑ONCEALED
OWE WL7RK TO ST[�Rr�p t DATE COMPLETED SITE DF SIGN pJUMSERI - t, P
L� 41 11 + u�i' IaI11 dG( !9 )
SEFNK:E ENTER BUILDING MANUFMTURER OF SIGN
CJ OVERHEAD R(3ROUND
DATE INSPSCT N REQUESTED DN(OR AS NEAR AS POSS EI A
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By GIVOW FULL AND TE INFt»INATION. L 'S $ MUST 6E OR GT Ep_
PRINT NAME AND ADDRESS
NMA_ E OF APPLICANT
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ZIP CODE LICENSE NO WHEN APPLICABLE
C� 85 Jahn Street yP1 4Y State Street ❑ 570 Delaware Avenue El217 Lake Avenue ❑ 202 Arterial Road
NEW YORK. NY 10038 , 74ILBANY, NY 12207 1 BUFFALO, NY 14202 ROCHESTER, NY 14WO I SYRACUSE, NY 13206
THE NEW YORK BOARD OF FIRE UNDERWRITERS
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RECEIVED
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