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2013-265
TOWN OF QUEENSBURY 742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201 Community Development-Building&Codes (518)761-8256 BUILDING PERMIT Permit Number: P20130265 Application Number: A20130265 Tax Map No: 523400-296-016-0001-016-003-0000 Permission is hereby granted to: STEWARTS ICE CREAM CO INC For property located at: 402 BAY Rd #396 in the Town of Queensbury,to construct or place at the above location in accordance with application together with plot plans and other information hereto filed and approved and in compliance with the NYS Uniform Building Codes and the Queensbury Zoning Ordinance. Type of Construction Value Owner Address: STEWARTS ICE CREAM CO INC PO BOX 435 Sign Total Value SARATOGA SPRINGS,NY 12866 Contractor or Builders Name /Address Electrical Inspection Agency Plans&Specifications 2013-265 STEWARTS SIGN freestanding 8'X 4' Change of copy only(top panel) $0.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: (If a longer period is required,an application for an extension must be made to the code Enforcement Officer of the Town of Queensbury before the expiration date.) Dated at the Town f Quee bury �e es SIGNED BY for the Town of Queensbury. Director of Building&Code Enforcement Office Use Only Town of Queensbury Building & Codes YiN 1 L 2013 Received: SIGN PERMIT APPLICATION Tax Map ID: t�Qfb. %' % (.c, '-� Permit No.: Permit Fee: $ Date &AtI113 Applicant Tax Map ID — J Address CK _ Property Owner Contractor/Agent: SCiM C Address Address Phone Phone Contact Person for Sign Code Compliance: r- 4�l—d_ Day Phone: Building Street Address: Site Plan,Variance,or Subdivision Approvals Location of proposed installation CJ Business Complex/Plaza/Mall name � r Business name ' Type of Sign proposed If sign is to be illuminated,indicate . _internal _external _-46ndesdrit _neon —other Do signs currently exist on property? ✓Yes _No(if yes,list all existing signage),2_1 205 Change of word/copy From to Q Sign Wording/CopyNE:fftonal Sign Size Length x Width =Total sq.ft. Sign Height(freestanding) Color&Material to be used This application creates a change in the New following existing site conditions(fill in all Change in number of signs from to applicable spaces) Change in setback for sign from to Change in size from to Change in hei ht of sign from to Declaration: To the best of my knowledge, the stemen con fined int application, toge r with the plans and specifications FV submitted, are a true and complete statement of all ppose work to be do on the described premises and that all provisions of the at ro Zoning Ordinance,and all other laws pertaining to the proposed work shall be complied with,whether specified or noted,and that such work is authorized by the owner. ✓APPLICANT SIGNATURE: C!c� te: 1 Declaration: I hereby authorize the a plicant to ce a sign on my property or building: ✓OWNER SIGNATURE: Date: Town of Queensbury Building&Codes Sign Permit Application 518-761-8256 OP ID: NW ACC3RL7" DATE(MM/DD/YYYY) �. CERTIFICATE OF LIABILITY INSURANCE 06/12/13 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER 518-587-1342 NAME: Marshall&Sterling Upstate 518-587-1348 PH2 FAx A11C No Ext: A1C,No 8 Circular St,Ste##4 POB 931 E-MAIL ADDRESS: Saratoga Springs,NY 12866 PRODUCER Harry D Bucciferro CUSTOMERID#STEWA-7 INSURER(S)AFFORDING COVERAGE NAIC# INSURED Stewart's Shops Corp INSURERA:Liberty Mutual Fire Ins Co P O Box 435 INSURER B; Saratoga Springs, NY 12866 INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCEADDL UBJ POLICY NUMBER POLICY YYFYY MM/DD� LIMBS LTR GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY X EB2611260852033 01/01/13 01/01/14 PREMISES Ea occurrence $ 100,000 CLAIMS-MADE a OCCUR MED EXP(Anyone person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 10,000,000 G ENT AG G R EGAT E L IM IT APPL I ES PER: PRODUCTS-COMP/OPAGG $ 2,000,000 POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea acadent) $ ANY AUTO BODILY INJURY(Perperson) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE HIREDAUTOS (Per accident) $ NON-OWNED AUTOS $ UMBRELLA LIAB E $ OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN TORY LIMITS ER ANY PROPRIETORIPARTNERIEXECUTIVE ❑ N/A E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required) Town of Queensbury Is provided Additional Insured status when required by signed written contract or agreement with respect to Shop#396,under the General Liability policy. CERTIFICATE HOLDER CANCELLATION r TOQUEEN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Queensbury ACCORDANCE WITH THE POLICY PROVISIONS. 742 Bay Road Queensbury,NY 12804 AUTHORIZED REPRESENTATIVE ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD STATE OF NBIV YORK WORKERS WORKERS' COMPENSATION BOARD COMPENSATION 328 STATE STREET SCHENECTADY, NY 12305 ANDREW M. CUOMO (866)750-5157 ROBERT E BELOTEN GOVERNORCHAIR COMPLIANCE WITH DISABILITY BENEFITS LAW (Pursuant To Section 220,subcLS of the Disability&nefits L.mv) EMPLOYER EMPLOYER'S U.I REGISTRATION NUMBER 14-1323607 Stewart's Shops. Corp. LOCATION OF OPERATIONS New York State ADDRESS(HOME OR MAIN OFFICE) OPERATIONS TO BEGIN ON ORABOUT: P.O. BOX 435 Self-Insured Status Saratoga Springs,NY 12866 Effective: 01/01/1992 Carrier I.D. No.: B630503 There are on file with the Workers'Compensation Board, documents indicating that the above-named employer has complied with the Disability Benefits Law with respect to all of his or her employees,in the following manner: MBy approved self-insurance pursuant to Section 211,subdivision 3 of the Disability Benefits Law. By a combination of approved self-insurance pursuant to Section 211,subdivision 3 Of F] the Disability Benefits Law and insurance with authorized insurance carrier(s). Date: March 13, 2013 (—&� By: Michele A. Kiuber, Secretary DB-155(08-12) THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION STATE OF NEW YORK WORKERS' WORKERS' COMPENSATION BOARD COMPENSATION 382 State Street, 3`d Floor U Schenectady, NY 13305 CEL9 to ANDREW M. CUOMO (866) 750-5157 ROHERTE.BELOTEN GOVERNOR CHAIR Office oftheS 1, Vim McCarroll, Secretary for the New York State Workers' Compensation Board, DO HEREBY CERTIFY,that STEWART'S SHOPS CORPORATION F.E.I.N. 14-1323607 has secured compensation to its employees as a self-insurer in the following manner: I—XI Pursuant to Section 50, subdivision 3 of the Workers' Compensation Law. F1Pursuant to Section 50, subdivisions 3 and 4 of the Workers' Compensation Law. (County, city, village,town, school district, fire district or other political subdivision) ❑ Pursuant to Article 5 of the Workers' Compensation Law. (County Self-Insurance Plan) The status of self-insurer was effective as of 03/09/1994 and such status still remains in fall force. IN WITNESS WHEREOF,I have hereunto set my hand and affixed the seal of the Workers' Compensation Board this 8 1h day of March 2013. STATUS CONFIRMED Michele K—lu-S-er" Self-Insurance Office J 1961 McCarroll, Secretary SI-12(08/12) THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION 44 11-4� g, 37 4i 49 d1 dl 12i'al °1� Lu Lo it �m I � I IL ou _ : IIIL IL ZI oil 00 _3 Omm R ------------ ------ -------------------- '00 N3k-JNVM) CIVION Ave rrs I e ° � I 4 G as9�AW I 1,05 : 1,15 e1. 3 Mn Regular ■ ■ rm r � DVS r.. .-u..� n;_rs � cauRere'�re�rr� � {� N HkNR(MRYj er*AM 3 SON SDE VONi.AFi�iF/�I`Y.•�f'iV�1V �--2'-6'�_! "X.ti.£iLi� _ _ _ SUE: 4S�rr. fvzpow mqm STM"o OM -weE cn.at uw -�'M.KK SAs Htuz NVR�e »K, •W pAY ROAD-t5AYQ-''3% 402$AY ROAD- 9 EENs"Y, NY DAl't REVivi�.s mnwu ay.M6 7�A � ecce Ijx`=C-r/ PO EOt A95 m=7<+- nn� 54;— � SIGN DE7"AIL