1992-063 y • f
CIERTIFICA TIE
TOWN OF QUEENSSURY
WARREN COUNTY, NEW YORK
L7atc__ ri 3 , _ t9 92
1 9 o fin
is is to certify that work requested to be done as shows+ by Permit No.
has been completed.
This structure may be occupied as a
Addition irs Office)
Location quakierRoad
Owner Gressmans corporation
By Order Town Hoard
TowN OF QUEENSBURY
Director of Hidg. do Code Enforcement
w
BUILDING PERMIT V4 ;PC
•a
TOWN 4F QUEENSBURY No. 92-063 I
WARREN COUNTY, NEW YORK o
Yt
l
PERMISSION is hereby granted to Grossmans Com@ration
OWNER of property located at 49 Quaker Road Street, Road or Ave,
in the Town of Oueensbury, To Construct or place a Addition to himi ldin�
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. CrIlp
1, OWNER'S Address is 3
200 Union Street
Braintree, NA a
N
2, CONTRACTOR or BUl LpER "S Marna
O
David J. Reid
a CONTRACTOR or BUILDER'S Address
PO Box 1044
Latham , MY 12110 �
.o
d. ARCHITECT"S Name
m
fb
70
iS
S. ARCHITECT'S Address
6. TYPE of Construction — (Please indicate by XI Sr
i ) Wood Frame l 1 Masonry ( } Steel ( } Steel fj re Sate V+
r-►
to
vo
7. PLANS and Specifications �
Q
iG7
No. 400 sq ft Addition to building as per plot plan specifications
and application t
8. Proposed Use
Contractors office
$ 40. 00 PERMIT FEE PAID — THIS PERMIT EXPIRES
March 4,
(if a longer period is required an application for an extension must be made to the Building and Zoning inspector of the
town of Queensbury before the expiration date.l
Dated at the Town of Queensbury this 4th Da March 19�___
SIGNED BY for the Town of Queensbury
Buildirg and o I mpec[or
y f
TIO W N a F WMENS191U R Y -
REVIEWED BY : QUEENS$URV
pr RECEIVES]
FEE PAID : >" ,r
PERMIT NO . : ✓ ;iJ / MAR 1992
BLDG. & CODE DEPr
BUILDING PERMIT APPLICATION
A PERMIT MUST BE OBTAINED BEFORE BEGINNING CONSTRUCTION . NO INSPECTIONS WILL BE MADE UNTIL
APPLICANT HAS RECEIVED A VALID BUILDING PERMIT .
All applicants spaces on this application MUST be completed and the signature of the
applicant MUST appear on the reverse side of this application .
Owner of Property : Grossmans Coporatian
P . O . Address : 200 Union Street , Braintr)ee , Mass . ( 517 ) 848-
PHONE 9}�$
Property Location : 49 !Quaker Rd . Glens FaLLs IV , Y ,
Tax Map No .
Has there been any split of this property since October 1 , 1988? Yes No
If yes , Planning Board Review is necessary ,
Subdivision Name , if applicable :
Lot No .
THE PERSON RESPONSIBLE FOR SUPERVISION OF WORK AS REGARDS TO BUILDING CODES IS :
David ,T . Reid , P . O . Box 1044 , Latham , N . Y . 12110 ( 518 ) 583-1517 - General Contractor
NATURE OF PROPOSED WORK : * ESTIMATED MARKET VALUE OF THE
Construction of new building * CONSTRUCTION :
X Addition to building * $ 270000 _
Alteration to building * COMPLETE INFORMATION REQUIRED BELOW :
( no change to exterior dimensions ) * Size of Property : ft , x ft .
Other work ( describe ) * Existing Building Size :
* 80 ft . x 200 ft .
* Proposed building - distance from
GROSS AREA OF PROPOSED STRUCTURE : * property line :
Ist Floor 400 Sq . Ft . * Front Yard
ft . Rear yard ft .
2nd Floor * Side Yards ft . and ft .
5q , Ft . * If on corner , setback from side street-
Other Floors ft .
asement
(not cellar or b ` Sq . Ft .
*
OCCUPANCY INFORMATION :
TOTAL FLOOR AREA : 400 Sq , Ft . * Primary Building - t
Size of New Structure : 19 . 7 ft . x 22 . 5 ft , * One Family Dwelling
* Two Family Dwelling
Founds i * Multiple Dwelling/No . of Units
Pier/ la Crawl /Partial /Full ( Circle One ) * Business
Nov of stories ( Habitable space ) 7 * Industrial
* Other
Height ( grade to ridge ) tc, ft .
If residential , no . of families : * IX addition , what will use be?
No . of rooms ( excluding baths ) : * � N
No . of bedrooms :
Nov of bathrooms : * Accessory Building :
Primary . heating system ; hcrt-
Type of fuel : Detached Garage - One/Two Car
CZ. * -
Nov
of fireplaces to a installed : * Attached Garage One/Two CarPrivate Storage Building
Will a woodstove be install ? • * Other
Central Air Conditioning : No
( OVER )
0 090
BUILDING PERMIT APPLICATION CONTINUED :
BUILDING SPECIFICATIONS :
Type of construction : wood frame , fire safe , etc , steel fire safe
Will any second- hand or ungraded lumber be used ? If so , for what? no
Foundation Wall Material : /B]r-x-;k Thickness : S'
Depth of Foundation below grade ( to bottom of footing ) : 5 '
Will there be a cellar? ncl _ Heated or Unheated ? Floor Sq . Footage :
Will there be a basement ? no Will any portion be used as living space ? no
If so , what portion ? Sq . Ft . Type of Use ?
Type of Roof : Sloped/Flat/ Shed/Other exjstina Material of Roof
Size , wood studs " x spacing " o . c . ; length ft •
Joists ( floor beams ) : 1st Floor NA x " ; spacing " o . c . ; span ft .
Joists ( floor beams ) : 2nd Floor x IN ; spacing o . c . ; span ft .
Overlays ( ceiling beams ) : x spacing IN
o . c . ; span ft .
Roof rafters : " x spacing o . c . ; span ft .
Roof trusses ( pre-engineered ) : spacing o . c . ; span ft .
Exterior Wall Finish : steel PrefmiAaed P3*als of what material ? Stele=i
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 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 : Nonapl:i_cable
SEPTIC SYSTEM : Distance from 2L9y private well ( including adjoining properties : ft .
( A separate application is necessary for any repair or new installation of septic system . )
NAME OF BUILDER & ADDRESS : DAvid J. Iaf3 , P.O . Box 1044 , Lathzm, N . Y. PHONE 583-1517
NAME OF PLUMBER & ADDRESS : Non MpIcipi.R PHONE
NAME OF MASON & ADDRESS : Michael Donlon , 208 Burgouyne Drive , Halfmoon , I�MONE 383-2372
NAME OF ELECTRICIAN & ADDRESS : altone Electric 400 Lang St Schenectady PHONE 370-0677
1
DECLARATION
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 p isions of the
BUILDING CODE , THE ZONING ORDINANCE , and all other laws pertaining t e propo ed wor shall
be complied with , whether specified or not , and that such work is uth i el pr t e ow er .
Signature � ~
Own , owner s a archi ect
contractor
----- -------
SPECIAL CONDITIONS OF THE PERMIT :
By :
Code Enforcement Officer
ENERGY CODE COMPLIANCE APPLICATION
TOWN OF EENSBURY , MARREN COUNTY - 9000 HEATING DEGREE DAYS
Co TOWN or QUEENSBURY
mp l i ante MMetlwefs : RECEIVED
PART 5 - Acceptable Practice Method - 1 b 2 Family Dwellings ( ONLY )I MAR 2 1992
PART 6 - Thermal Rating - Component Trade Offs - 1 8 2 Family Dwelling
Multi - Family Dwe l l i ng�lmDG. $ CODE DEFT.
( 3 Stories or Less )
PART 4 - Design By Component Performance - Commercial Buildings - Hi - Rise Residential
PART 4 6 - Compliance Methods Require Submission of Worksheets
David J Reid Grossmans
P . O . Box 1044 , Latham , N . Y . 12110 49 Quaker Rd . Queensbury , N . Y .
A LICANT5S 1&0�� PROPERTY L ION
PART YNETHOO OF COMPLIANCE BY ACCEPTABLE PRACTICE : .
1 . Gross Floor Area - 400 5q . Ft .
2 . Type of Heat - Elec . Base Board Other Gas hot ais
3 . Is Building Mechanically Cooled ? x YES NO
4 . Percentage of Area of Windows and floors Over 17% x Under 17%
THE R-VALUES GIVEN ON THIS SHEET MIST CORRESPOND TO PdX TA
THE R-VALUES SHOWN ON PLANS SUBMIT MI R E Q U I R E D
B�seb rd
5 . Insulation Values : Actual Shown E Heat
A . Roof A Floors exposed to ambient temperature - - 5-oeil n
Be Exterior Walls r-19
C . Glazed Area R
D . Exterior Doors R
E . Floors over unheated spaces R
F . Edge of Slab on Grade ( Heated Building ) 50 � � rm�,
G . Basement/Cellar Walls (Above Grade ) R
H. Basement/Cellar Walls ( Below Grade ) R
i . Heating/Cooling - Ducts - Piping in Unheated Space R
6 . Service ( Domestic ) Not Water Heating Device
A . Conforms to mini efficiency per code YESNTR NO
77'TuCOOL MAXIMUM SETTING 140• - WILL WT BE EXCEEDED
ImsPECTOR ' S REMARKS
TOWN OF QUEENSBURY
FIRE MARSHAL
QTELEPHONE � ( 51 NEW 0 8 ) 792- 583RK 4 2
FIRE MARSHAL INSPECTION REPORT
REQUEST FOR INSPECTION RECEIVED
NAME
LOCATION
�-
PERMIT#
HATE
APPROVED
N/ A ✓ NO
EXITS
AISLE WID HS
EXIT SIGNS
EMERGENCY LIGH ING
FIRE EXTINGUISHERS
AUTO , EXTINGUISHING ST M
HOOD INSTALLATION
AUTO , SPRINKLER SYS EM
ALARM SYSTEM
INTERIOR FINISH f
STORAGE :
CLEARANCE T SPRINKLERS
CLEARANCE T HEATING UNITS
REQUIRED SIGN F.
`1
CHIMNEY ✓
WOOOSTOVE
FIREPLACE-MA ONRY
FIREPL ACE- F TORY UILT
REMARK
K T H S A
ARRIVE
DEPART AIINSPE OR
THE NEW YORK BARD OF FIRE UNDERWRITERS ".
BUREAU OF ELECTRICITY
41 STATE STREET. ALBANY, NEW YORK 12207
r Application i ' s , . , � , ,
Dote .
THIS CERTIFIES THAT
only the electrical egnipmcrat as described belowand Introduced by
t ""Sod on the above application number in the promiere of
b4 v, r � Lwl ,` wry
Black Lotin te following location, �y 8a"MaTI,t ',.Slit FT. 0 Snd Fl. Section
h
xoas examined on AP"I ' S72 { • R2w and faund to be in compliance with the requirements of this Boar$.
rr RxTURE FIXTURES RANGES COOKLNG PECKS OVEFlS DISK WASHERS EXHAUST FANS
OUTLETS ECS"ACLES SWITCHES INCANDESCENT FLUORESCENT OTHER AMT. K. K. W. AMP. K.W- AMP. K- W. AMP. N. P-
8 3A .5 I fP
DRYERS FURNACE, MOTORS FUTURE A04PUANCE PREDERS SFECLAL REC'rT TWE CLOCItS TELL UNIT HEATERS MLUL7FOLLTLET DIMrAlIERS
SYSTEMS AMP, WAtt5
AMT, K. W- CNl H. P- G►5 H. P. AMP. NO. A. W. G. AMP. AMP. AMP. AMPS. TRANS. AMP. H. P. FN1. OF FEET
SERVICE DISCONNECT No. of S E R V I C E
UNiITpt . "Mc!c, cOTFu. A. W. No. of Ns-LEG A. W. G. Ho. OF NEUTRALS OF NEUTRAL
wMT. AMP. TVPE MASTER
I ./ 7W 1 0 7w 3 A 5W 30 svr jr OF CC. CSND. OF HIAEGEQUI ..
OTHER APPARATUS,.
� �► {-9 GIIR... 11d
t --
I. . , . - BRANCH MANAGER
. . i.< , Ir
Per
This Certificate most not be altered in any manners return to the office of the Board if incorrect. Inspectors may be identified by their credenfiak.
COPY FOR BUILDING VEPARTMENT. THIS CDPY OF CERTIFICATE MUST NOT BE ALTERED IN ANY MANNER.
745 .4447
e TOWN OF QUEENSBURY
9eY ar HaviJand Arid, p„aensG++rf • NY 128arg972X
13 ICI in9 Codes pep
zNS, 'ToR ' S REPORT
411192 19�
GROSSMAN ' S
FROPZRTV LOCATION
QUA .I<ER ROAD
pWNER t7R TENANT
BUILS32L3G x SE RA-- SIGNS OTHER
neces``s `� r � .before
REMri.RKS : In s P
'Use of this sp c2 _ f
Final Constructi , 72,
Final FZectrical :
Fire Mars
Final bY
required
Certificate of
t]c Upan is
or use
this space -
,before occupant
ff h stioons
CONTACT THIS OFFICE mr"nxx
IN EC OF
"HOME OF NATURAL BEAUTY . . . A GOOD PLACE To LIVE"
SE17LED 1769
T0M OF QUEEKSBURY
BUILDING 53 BA
O Y ROAD DEPARTMENT
QUEENSSURY , NEW YORK 12804
TELEPHONE ( 518) 745- 4447
BUILDING ,%SpECTORlS REPORT
a
REQUEST FOR IlISPECTIOri RECEIVED i
NAME
LOCATIQli7Z C) 0
PERMIT -
DATE
TYPE (}F STRUCTURE APPROVED
RECHECK
N A YES NO
III I FOOTINGS/ IERS
MONOLITHIC POUR FORM
N PLA
REINFORCEMETOR IS RESpOKSIBLE
THE CONTRAC pRpTECTIdN FROM
FOR PROVIDItiG HOURS F�LL0YIIH6
FREEING FOR THE C RETE.
THE PLACEMEfiC OF
MATERIALS FOR THIS Pl1RPO E ON SITE r
FOUNDATION/WALK POUR
REINFORCEMENT IN PLACE _ ----
FOUNDAT ION/DAMPROOFING� a
BACKFILL APPROVAL
ROUGH PLUMBING E IS N ACESPLUMBING
PLUMBING UNO RVSLAB
FRAMING : HEAD
JACK S /
BRACING/BRfDGING_� _ —
JOIST HANGERS
JACK POTS S/14AI B�
14EATING ROUGH SIN
NSULATION = R—
FOUNDATION L ER,IOR R—
FOUR ION WALLS E R—
FLOORS R—
WALL.S R—
CEILING R PI ING INUNHEA ED
DUCT WORK
SPACES
dlor? ade�l
� 3d
ARRIVE $,
DEPART WiNS CTOR
s
A`
TOWN OF QUEENSSURY
BUILDING 53D BAY ROAD CODES DEPARTMENT
QUEENSBURY
( 5I8 )SEW 0R9�- 583?�
BUILDING INSPEC OR' s SPORT
REQUEST FOR INSPECTIOM RECEIVE
y
NAME
LOCATION
PERMIT #
DATE
TYPE OF STRUCTURE APPROVED
RECHECK N /A YES NO
FOOTINGS/ PIERS FORM
MONOLITHIC POUR _----�-�---
REINFORCEMENT IN PLACE.
THE COg, RACTOR IS RESPONSIBLE
FOR PROVIDING PR�RSYFOL p�YN6
FREEZING -FOR 48
THE PLACEKENT OF
MATERIALS FOR THI PURPOSE ON SITE
'
FOUNDATION/WALL PO
REINFORCEMENT IN PL CE
BACKDF I LLFOUNO G
APPROVAL
ROUGH PLUMBING E
PLUMBING VENT/ VEN
PLUMBING UNDER SLAB
FRAMING
JACK STUDS /HEADERS
BRACING/ BRIDGING
JOIST HANGERS_ ---
.TACK POSTS /MAIN EAM
FIRESTOPPING
WALLS
CEILING
FIREWALLS
HEATING ROU - IN
'INSULATION=
FOUNDATI N WALLS INTERIOR
FOUNDAT ON WALLS EXTERIOR R-
FLOORS R-
WAL.LS �� R-
CEIL
DUCT WORK OR PIP NG IN UNHEATED
SPA ES
REMARKS = LJf'i �
. 1� t'Jli
p
ARRIVES —
DEPART y r IN5PECTO
TOWN OF QUEENSBURV
BUILDING 0 BAY S DEPARTMENT
.53
AD
UTELEPHONE � NEW 0
( 518) 745- 4447
BUILDING INSPECTOR' S REPORT
REQUEST FOR INSPECTION RECEIVED.,
#LAME
LOCATION` � y
DATE
TYPE OF STRUCTURE
APPROVED
RECHECK N/A IYES1 NO
FOOT NGS/ IE S
MONOLITHIC POUR FARM
REINFORCEMENT IN ACE
THE CONTRACTORS
SP SIBLE
FOR PROVIDING PROTE T110"
FOLLOWING
FREEZING FOR 48 H
THE PLACEMENT OF THE ONGRET =
MATERIALS FORPU
FOUNDATION/WALLHIS POUR POSE �!4 SITE
REINFORCEMENT IN PLACE
FOUNDATION/DAMPROOFING
BACKFILL APPROVAL
ROUGH PLUMBING
PLUMBING VENT/VET IN E
LUMBING U DER SLAB �
JAI K D EAU
BRACI /BRIDGING S
JOIST HANGERS
JACK POSTS/MAI B AM'•
HEATING ROUGH- IN
INSULATION : _
FOUNDATION W L
FOUNDATION 'HALLS EXTERIOR R-
FLOORS R_
WALLS
CEILING
DUCT WOR €} PIPING IN UN EA ED
SPACES
REMARKS :
ARRIVE
DEPART Ii "} iN PEC OR
TOIM OF QUEENSBURY
BUILDING AND BA CODES ROADPARTMENT
QUEENSBURY , NEW YORK 12BO4
TELEPHONE ( 518 ) 742- 5832
BUILDING INSPECTOR` S REPORT
REQUEST FOR INSPECTION RECEIVED
f
NAME
LOCATION ;q
DATE • PERMIT f_ � /
TYPE OF STRUCTURE,
APPROVED
RECHECK N/A YES NO
NGSjl
POUR
/ REINFORCEMENT IN PLACE�~
THE CONTRACTOR IS RES S 6 1F
FOR PROVIDING PRiOTECTION FRO"
FREEZING FOR 48 HOURS FOLLOWING
THE PLIICEMEKT OF THE CONCRETE.
MATERIALS FOR THIS PURPOSE N SITE
FOUNDATION/WALL POUR
REINFORCEMENT IN PLAC
FOUNDATION/DAMPROOFING�
BACKFILL APPROVAL
ROUGH PLUMBING
PLUMBING VENT/VEN IN L C
PLUMBING UNDER SLAB
FRAMING : R
JACK STUDS/HEADERS��
BRACING/BRIDGING��
JOIST HANGERS
JACK POSTS /MAIN BEAM
FIRESTOPPING
WALLS
CEILING
FIREWALLS
HEATING R UGH- IN
INSULATION :
FOUNDATION WALLS ERI R
FOUNDATION WALLS EXTERI RR-
FLOORS
WALLS
CEILIN
DUCT WORK O P IP I G U H EA
SPACES
EMA K p
l�ru � �c3tL5 �rP -
Y3
ARRIVE :�5r F
DEPART 5 S E R
TOWN OF OyEENSIBURY
BUILDING 53 D BAD ROAD DEPARTMENT
QUEENSBURY , NEW YORK 12804
TELEPHONE ( 518 ) 792- 5832
BUILDING INSPECTOR' S REPORT
REQUEST FOR INSPECTION RECEIVED
NAME
LOCATION
FEplIIT
DATE #�Y�
TYPE OF STRUCTURE
APPROVED
RECHECK NIA YES I . N.0
FOOTINGS/PIERS
MONOLITHIC POUR FORM
REINFORCEMENT PLA
RES E
THE CONTRACTOR
FOR pROVIDING PR TEIRS FOLoN ING
FREEZING FOR •8 E .
THE PLACEMENT OF E CONC
MATERIALS FOR THIS URPO ON SITE
FOUNDATION/WALL POU
REINFORCE14ENT IN PLA E
FOUNDATION/DAMPROOFI
X BACKFILL APPROVAL
ROUGH PLUMBING
PLUMBING VENT/ VEN S LA E
PLUMBING UNDER SLAB
FRAMING :
JACK SNDS /HEAD S�
BRACING/BRIDGIN
JOIST HANGERS -
JACK POSTS /MAI SEAM
FIRESTOPPING
WALLS
CEILING
FIREWALLS
HEATING ROUGH- N
INSULATION :
)t' FOUNDATION WALLS 1 E IOR R-
FOUNDATION WALLS EXTERIOR RR-
R-
WA LLS R-
CEILING
DUCT WORK OR PIPING IN N EA E
SPACES
REMARKS =
r
ARRIVE�� -
DEPART ID •t__�-�-- NSP TOR
TOWN OF QUEENSBURY
BUILDING AND CODES DEPARTMENT _�-
531 BAY ROAD y
QUEENSBURY : NEW YORK 12804
TELEPHONE ( 518 ) 745-4447
BUILDING INSPECTOR' S REPORT
REQUEST FOR INSPECTION RECEIVED
J
LOCATION
DATE PERMIT # �tr
TYPE OF STRUCTURE
RECHECK APPROVED
N/A YES NO
XFOOTINGS/PIERS
MONOLITHIC POUR FORM
REINFORCEMENT IN PLACE
THE CONTRACTOR IS RESPONSIBLE
FOR PROVIDING PROTECTION FROM
FREEZING FOR 48 HOURS FOLLOWING
THE PLACEMEKT OF THE CONCRETE.
MATERIALS FOR THIS PURPOSE ON SITE
FOUNDATION/WALL POUR
REINFORCEMENT IN PLACE _
FOUNDATION/DAMPROOFING _
BACKFILL APPROVAL
ROUGH PLUMBING
PLUMBING VENT VENTS IN ACE
PLUMBING UNDER SLAB '
FRAMING :
JACK STU S/HEADER
BRACING/BRIDGING
JOIST HANGERS -
JACK POSTS/MAIM BE
HEATING ROUGH- IN
INSULATION :
FOUNDATION W LL INTERIOR R-
FOUNDATION WALLS EXTERIO R-
FLOORS R-
WALLS R-
CEILING R-
DUCT WORK OR PIPING IN; UNHEATED
SPACES
REMARKS :
ARRIVE ! % 36
DEPART
INSPECTOR
TOM OF QUEENSBURY
BUILDING AND CODES DEPARTMENT
531 BAY ROAD
QUEENSBURY , NEW YORK 12804
TELEPHONE ( 518) 792- 5832
BUILDING INSPECTOR' S REPORT
REQUEST FOR INSPECTION RECEIVED
NAME
LOCATION f
DATE PERMIT #
TYPE OF STRUCTURE
RECHECK APPROVED
N/A YES NO
dO NG / I R
MONOLITHIC POUR F ' M
REINFORCEMENT IN PLACE
THE CONTRACTOR IS RESPONu
FOR PROVIDING PROTECTION FROM
FREEZING FOR 48 HOURS FOLLOWl"G
THE PLACENM OF THE CONCRFTE.
MATERIALS FOR THIS PURPOS ON SITE
FOUNDATION/WALL POUR
REINFORCEMENT IN PLACE
FOUNDATION/DAMPROOFING
BACKFILL APPROVAL
ROUGH PLUMBING
PLUMBING VENT EN IN A
PLUMBING UNDER SLAB
FRAMING :
JACK STUD {HEADERS -
BRACING/ BRIDGING
JOIST HANGERS
JACK POSTS /MAIN B
FIRESTOPPING
WALLS
CEILING
FIREWALLS
HEATING R UGH- N
INSULATION :
FOUNDATION W LL I E I R
FOUNDATION WALLS EXTERIOR R-
FLOORS R-
WA LLS
CEILIN -
DUCT WORK d PI ING N UNHEA ED
S PACES
R EMA c ll & x, I.f''Clc 1-%v-T�( +C1 v o r'
ARRIVE N CINS
DEPART C R
YOU ARE HEREBY REQUESTED TO
INSPECT .AND ISSUE CERTIFICATES
FOR THE FOLLOWING ELECTRICAL
EQUIPMENT TO BE INSTALLED BY
THE UNDERSIGNED _
CRY OR VILLAGE lowom IIP STY
nawron
STREET AND RC OR no AD POLE NUMBER
Stzoot
BETWEEN VA4M TWD CROSS SfREWM Is PnEp&ISFSi LOCATEDq S0=10N HA.00K LOT
DCCURi1NITS HAMS BULDING CK CUiM 410Y
OVII M'S NAME AND ADDRESS HOME TELEPHONE NUMBER
Di
CORI FMT SUPPLIED BY FFInU THEIR OFFICE 1MDRK TELEPHONE MJMBER
N I]�1li is , . I . . 0 ♦ .
NEW ow WORK IS NEW AWRIONAL ❑ OEFECtS REMOVED ❑
UST BELOW ALL EQUIPMENT WHICH YOU INSTALLED
_ NUMBER OF OUTLETS Na of FDctures iL MUFORS HEATERS BRANCH BEL
tioFl LarRP Aeo"AwFes CIRCUITS - ONLY
Calling S;d* ARACh' SwIlCh PSrOmA arBOM Na TYPB Each N(I. EH.RiRa R Na p.W.G. L .
GoLloo INSF419CTION
1.
oLlr-
SSIDE
SUB-
BASE
BASE-
MENT
ISI
FL.
2nd
FL
31d
Ft_
REMARKS: LIST OTHER ELECTRICAL DIPMES NOT SET FORTH ABOVE.
I - I A
THIS APPLICATION IS INTENDED TO COVER THE ABOVE-LISTED EQUIPMENT TO BE INSPECTED, BUT IF AT TIME OF iNSPECTION, THERE IS
FOUND AM TIONAL £OUIPMENT NOT ABOVE LISTED: YOU ARE ALI THORIZED TO MAKE THE INSPECTION AND ADJUST THE FEE TO COVER
THE ADDITIONAL EQUIPMENT, AS PROVIDED BY THE APPLIGWT-
SIZE OF MNNS FEEDERS ELECTRIC SIOHSA.AMPS 1L)VkL Vwrm
OHARM.RER OF AT~ ❑ F3XPOED GAS TORE SIGWTRMSFORMEff OF
FOE 1NXW TO BE SIANrED DATE C OAP ETED SJZE OF SKiN(NUMBEm) C-AVACRv
SETWICE ENTERS RUN-DING MANUFAMURER OF$IGN
❑ OVERHEAD ❑ ummennAOONo
DATE WSPECTIpN REQUESTED ON(DR AS NEAR AS POSSX"E
WON
PRINT NAME AND ADDRESS
NAME OF APPLICANT DATE OF APPLIC4JFOM OFAPPl cow
STREET A �SS LEPHON ND.STREETm
CITY OR POST ZI P CODE LICENWND. WHEN APPILICABLE
85 John Street 41 State Street II 670 Delaware Avanua 217 Lake Avenue 202 Arterial Road
K,NEW YOR NY 1003a AL13ANYP NY 12207 ! ❑ BUFFALO, NY 142 I ❑ ROCHESTER, NY 14606 SYRACUSE, NY 13206
(212) 2273700 I (518) 463-2122 IIII (716) 864-1156 (716) 254-0141 I (315) 463-8552 x
THE NEW YORRK BOARD OF FIRE UNDERWRITERS
'N
5
p 1A I +-J A /A Lj iA 0 Ic-
A rNJ
> C-- 14--t W A YA)Q-F-A �4L.� A
50
\V C> P VF Yf xl�A
\AT,;9
F rz
i3o 4L
moo
2 o Al
00
SHiNq Lta
PA4-�
a) o o
Q- Ci AN S i J; A'
40
DITCH
FT.
Y7
+
VIN",
3m
9
1,
1AWR
wk,
11111MIll