Permit Application and Sign Specification Sheets I�ECEI\/E�
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omw use onN O 2079
TOWn of QYBBnabury Building 8 CodBS Received: ��� .3n a.��T II�i�OFFICEU RY
91GN PERMIT APPLICATION Tex MeP o: _�,na,! -(-.(03
,. Permll No.: S 1 E�� -Jio -.S.n I
Pelmll Fee: s :�+-�-� 1
Daia Jar[arary B 01 APPllcent I dl 1
Tu Mvp ID 302 B_1-62 gdtlresa L In®8116 AVe
zonma —CT TioV_ NY 12180
Properly Owner T6 t7l1AK R 1 R ConVaClPr/ I
Addresv 15 6reaRlda it -Ira Ape^P$Ign 3tudl0. Ino. [Ron L v )
- Adtlreaa 1. n0a a VB .
�)/'_ NY 1DB06 SrO�_ NY 19'An
Phone F18 Too 'a4 O Pkuna 69 i� �665187.
contaPt Pereon far Sign Coda cpmpnanw: Ron LBVaagUO Oay Phone: 518.266.087T
Bulltlln9 arraet Addreae: T4 I�YaKer Road �
' 9I[a Plan.Varlenw.or BubdWlalon Apptovala
Iswnw of pmpoevtl Inalallaupn 74 QUAKER ROAD Town Of Quaena u
Buclnaca Campvz/PIaz�Malr name N/
Buvinen name
TYPE ni sign prepoved F seta din 1 one B I
If a1g11em ba llltanlnas3d,intllmb j[.Inbnfvl _axbmal _IneMtlbBCBM Freon �plllar
Do alpna wrtvNly axlet on proparp? _2L Yea _Na Mys.Ilet all azletlnp vipnepa) t WALL E Mod IB
CM1anpa olwortl/copy FPom Io
Slgn Waminp/copy A[8R with Ora bio Lo 0
sign sv I.errglM1 sa- x wmm m TONI q. sg aw..apapmpanpn sheet
sign I-lelglrt(naeemndme) za•
Cdw 6 Mabdel M ba uvatl BIavK Ba round wYbi WM111a T M 6 Blua Ora M1lo 3/'I B"WM1IIB Lexan Fawv
Thle ePPllratbrr cmeba a dtanpa In Na New Faaa PBnafa OrbY
Idlvwing adstlrq ails contlitlona(1111 In dl CM1arge In number ol•pea frdn b
eppllrabla epewv) _Cheops In netbnok Tor alpn bom to
CM1anpa Inaba Iran W
_Change Ir.M1e1pM of vlgn bm tp
Dadareu^n: Tv NB treat of my knowledge,ere etntvmenLe conlalned m We appllwtlon,together wIN the plena end apavmwtlbna
eutllNttetl.era a true srtl wmplata statement o/all prepoeetl work kf ba done w ere deacdbed pramleae and that eV proNelone of Ike
Zoning Ortllnarca,antl all oNar Iowa perfalNna tv Ike prvpnead wodc eM1all ba eompllad wIM,whaNer npeelpvd or noletl.end that each i
work le aunrerizatl by 1M1a owner.
APPLICANT-PRINT NAME ROna)d J.Lava+ 11B 3I n.41Y IO IIIC
APPLICAkT-SIGNP.TURE: \ �OA/O/'L� a Dnta: Jent10N 2fi.2019 �
Declere0vn- 1 Hereby auNoriza[M1B Bppli®M fa place a p o my properly ar bulW Ing: ,
OWNER-PRINT NAME: NBI n
OWNER$16NATLRE: Date: J 26 $O1B
TOWr1 p(GlrNnebury Bulklllg64btl®Slpn parmn ApPlkatbrl 61B-T61-B288
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