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94-710 CERTIFICATE OF OCCUPANCY TOWN OF QUEENSBURY WARREN COUNTY, NEW YORK Date October 25 19 95 This is to certify that work requested to be done as shown by Permit No. 9 4 7 t Q has been completed. This structure may be occupied as a 2- CAR ATTACHED GARAGE 1382 BAY ROAD Location owner FITZGERALD . RANDALL TAX MAP NO. 2 3-1 30. 2 By Order Town Board TOWN OF QUEENSBURY Director of Bldg. & Code Enforcement BUILDING PERMIT TOWN OF QUEENSBURY No. 94-710 WARREN COUNTY, NEW YORK F, I w 0 PERMISSION is hereby granted to Randall Fitzgerald OWNER of property located at 1382 Bay Road Street,Road or Ave. N• in the Town of Queensbury,To Construct or place a 2—Car Attached GArage N at the above location in accordance to application together with plot plans and other information hereto filed and (D approved and in compliance with the Town of Queensbury Building and Zoning Ordinance. Fi N 1. OWNER'S Address is Same 2. CONTRACTOR or BUILDER'S Name A� Same N 3. CONTRACTOR or BUILDER'S Address N W CC 4. ARCHITECT'S Name C—' 5. ARCHITECT'S Address I 6. TYPE of Construction—(Please indicate by X) Ii (X)Wood Frame ( ) Masonry ( )Steel ( ) Ai Fi 7. PLANS and Specifications Sv No. 484 sq ft 2-Car Attached Garage as per plot plan specifications N 8. Proposed Use Attached 2-Car Garage $ 1 9 ao PERMIT FEE PAID —THIS PERMIT EXPIRES December 12 , 19 95 (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.) Dated at the Town of Queensbury this 12th Day of; 1994 SIGNED BY for the Town of Queensbury Building and Zoning n ctor ^ 4 • TOWN OF QUEENSBURY REVIEWED BY: COMMUNITY DEVELOPMENT DEPARTMENT 't " ~, BUILDING & CODE ENFORCEMENT ' FEE PAID: ', £,, 531 BAY ROAD QUEENSBURY, NEW YORK 12804 PERMIT NO. / (518) 745-4447 U 994 BUILDING PERMIT Received A PERMIT MUST BE OBTAINED BEFORE BEGINNING CONSTRUCTION. Q hs►� . PECTIONS WILL BE MADE UNTIL APPLICANT HAS RECEIVED A VALID BUILHI�itdgte,'ERMIT All applicants ' spaces on this application MUST be completed and the signature of the applicant MUST appear on the application form. OWNER OF PROPERTY: ii4-i1:k htL 17 f1y2/1 lu/ Mailing Address : /302 6, ;Ni ,.,,,f_l,g,f.;.-,e,..,,e_v if)if"2-Vi--f Telephone Number(s) : Work Home 7y10- 0f2,3`i Other PROPERTY LOCATION: Tax Map Number: Section 23 Block / Lot 3c,2 Subdivision Name: , ///- Lot No. NATURE OF PROPOSED WORK: ESTIMATED MARKET VALUE OF THE CONSTRUCTION: $ /C,zZ NEW BUILDING: RESIDENCE/COMMERCIAL OCCUPANCY INFORMATION: ADDITION TO BUILDING: PRIMARY BUILDING - RESIDENCE/COMMERCIAL Single Family Dwelling ALTERATION TO BUILDING: Two Family Dwelling RESIDENCE/COMMERCIAL Family Dwelling (NO CHANGE TO EXTERIOR SIZE) Office X OTHER WORK (DESCRIBE BELOW) Mercantile .,4 ,, 24:,,,,e,yrhe, ,,, Warehouse Manufacturing Other GROSS AREA OF PROPOSED STRUCTURE: 1ST FLOOR 4 SQ. FT. IF ADDITION, USE OF NEW ADDITION: 2ND FLOOR SQ. FT. OTHER FLOORS SQ. FT. (not unfinished cellar or basement) ACCESSORY BUILDINGS : Detached Garage - One/T • .r TOTAL FLOOR AREA: .'3`/ SQ. FT. X Attached Garage - On:!Two Ca Private Storage Building SIZE OF NEW STRUCTURE : Commercial Storage Building Other 2 FEET X 24/ FEET Foundation Type: C.;-.,,,4.:4e.4.1./t &1 .:4t. Will any second-hand or ungraded Number of Stories : / / lumber be used? If so, for what? (habitable space only) / 1tie) Height (grade to ridge) : 43 feet Type of Heating System: Number of fireplaces and/or woodstove (circle all which applies ) to be installed: Electric / Oil / Gas / Wood Forced Hot Air / Baseboard / Other PERSON RESPONSIBLE FOR SUPERVISION OF WORK AS REGARDS TO BUILDING CODES IS : NAME OF BUILDER/ADDRESS/PHONE : NAME OF PLUMBER/ADDRESS/PHONE : NAME OF MASON/ADDRESS/PHONE : gffit% Jt,,1,4-4. 7G%f -007'7 NAME OF ELECTRICAN/ADDRESS/PHONE: DECLARATION To the best of my knowledge the statements contained in this appli- cation, together with the plans and specifications submitted, are a true and complete statement of all proposed work to be done on the described - -o,,,; roc mnA +-hat all nrnvi Ri nnp of the Rui ldino Code. the Zoning Ordinance (518)761-8256 TOWN OF ODEEENFORC BUILDING & CODE ENFORCEMENT 742 BAY RD., QUEENSBURY NY 12804 INSPECTOR'S REPORT: ARR//114 DEPART INT , REQUEST FOR INSPECT ON RECEIVED: NAME 1 4eA,/ LOCATION DATE / ,3/ PERMIT I Si' 7/6 TYPE OF STRUCTURE: RECHECK APPROVED N/A YES NO FOOTINGS/PIERS MONOLITHIC POUR FORM REINFORCEMENT IN PLAC- THE CONTRACTOR IS RES••NS -LE FOR PROVIDING PROTE TION F • FREEZING FOR 48 HOURS FOLLONI THE PLACE- MENT OF THE CONC• .. MATERIALS FOR' HIS PURP'SE ON SITE FOUNDATION/WALLPOUR REINFORCEMENT IN PLACE - -1 FOUNDATION/DAMPPROOFING BACKFILL APPROVAL PLUMBING VENT/VENTS IN PLACE ROUGH PLUMBING PLUMBING UNDER SLAB FRAMING: JACK STUDS/HEADERS - BRACING/BRIDGING JOIST HANGERS JACK POSTS/MAIN BEAM AIR INFILTRATION BARRIER HEATING ROUGH-IN INSULATION: FOUNDATION WALLS INTERIOR R- FOUNDATION WALLS EXTERIOR R- FLOORS R- WALLS R- - CEILING R- DUCT WORK OR PIPING IN UNHEATED SPACES R- 1 (518) 761-8256 TOWN OF QUEENSBURY 16I BUILDING b CODE ENFORCEMENT 742 BAY RD., QUEENSBURY NY 12804 INSPECTOR'S REPORT: ARR IIlI/�0 DEPART INT 'OK � REQUEST FOR INSPECTION RECEIVE : NAME ell CA LOCATION (:1°E.s° / Al -A 6- DATE ^— " ` PERMIT A TYPE OF STRUCTURE: `( <S. RECHECK APPROVED N/A YES NO FOOTINGS/PIERS MONOLITHIC POUR FO REINFORCEMENT I PLACE THE CONTRACTOR IS RESPONSIBLE FOR PROVIDING PROTE TION FROM FREEZING FOR 48 HOURS FOLLOWING THE PLACE- MENT OF THE CONCRETE. MATERIALS FOR THIS PURPOSE ON SITE FOUNDATION/WALLPOUR REINFORCEMENT IN PLACE FOUNDATION/DAMPPROOFING DACKFILL APPROVAL PLUMBING VENT/VENTS IN PLACE _ ' t,'ROUGH PLUMBING PLUMBING UNDER SLAB JI��FEL�ING: JACK STUDS/HEADERS BRACING/BRIDGING JOIST HANGERS JACK POSTS/MAIN BEAM AIR INFILTRATION BARRIER HEATING ROUGH-IN ✓INSULATION: FOUNDATION WALLS INTERIOR R- FOUNDATION WALLS EXTERIOR R- FLOORS R- - WALLS R- CEILING R- DUCT WORK OR PIPING IN UNHEATED SPACES R- Qt1QA 0 3 Pill/ TOWN OF QUEF:'iSHhJRY BUILDING & CODE ENFORCEMENT Vrne 742 BAY ROAD QUEENSBURY NY 121104 (518)745-4447 is ARRIVE: / DEPART"'Z7J FINAL INSPECTION REPORT - RESIDENTIAL DATE IN ECTION/ REQUEST RECEIVED: / ��_ iS S NAME CVG Cr1/4 l t RitAZI-K)1 LOCATION ^24,_` DATE PE IT I L_7/ TYPE OF STRUCTURE (C*Y < -� FOOTINGS FOUNDATION BACKFILL FRAMING ROUGH PLUMBING SEPTIC INS ATION FINAL ELECTRICAL _ WOODSTOVE OR FIREPLACE N/ YES NO CHIMNEY HEIGHT/B VE T/HEIGHT PLUMBING VENT / ROOFING _ J EXTERIOR FINISH DECK/PORCH/STEPS/RAILI°'S V1 t� ILLlt'.1 fLJES FURNACE/HOT WATER OP'RAING INTERIOR TRIM/PRIVA' ••RS FINISH FLOORS: 1111 BATH/KITCHEN WA ERTIGH OTHER FLOORS S EEPABLE OTHER FLOORS •'RPETED STAIR CLEARANCD RAILINGS SMOKE DETECT°• J BATHROOM FAN ✓f PLUMBING FIXTURES Y FOUNDATION INSULATION GARAGE FIRE PROOFING DOOR C LLyRS -- - FI L ELECTRICAL Ø '/cc f SITE PLAN/VARIANCE REO. FINAL SURVEY PLOT P A OK TO ISSUE C/O OR C C V 71.3-9z7z- TOWN OF QUEENSBURY BUILDING & CODE ENFORCEMENT 531 BAY RD., QUEENSBURY NY 12804 /ff) l t l INSPECTOR'S REPORT: ARRI44 DEPART /" IN'T''✓ REQUEST FOR INSPECTIONe �f RECEIVED: /®/2�/�4.' NAME — fi r246/2- g'L-,A c [[[ LOCATION ! �[84/ /ea. DATE `�f/� `�� PERMIT # '770 TYPE OF STRUCTURE:/// l 5,iQr�- ,'' RECHECK APPROVED N/A YES NO FOOTINGS/PIERS MONOLITHIC POUR FORD REINFORCEMENT IN PLATE THE CONTRACTOR IS RES•ONSIBLE OR PROVIDING PROTE TION ROM FRE ZING FOR 48 HOURS FOLLOWINe THE P .CE— MENT OF THE CONCRETE. MATERIALS FOR THIS PURP• E IN SITE FOUNDATION/WALLPOUR REINFORCEMENT IN PLACE FOUNDATION/DAMPPROOFING BACKFILL APPROVAL PLUMBING VENT/VENTS I PLACE ROUGH PLUMBING PLUMBING UNDER SLAB FRAMING: JACK STUDS/ EADERS -- ` BRACING BRIrGING JOIST HANGE'S JACK POSTS/ *IN BEAM AIR INFILTRATION B RRIER HEATING ROUGH—IN INSULATION: FOUNDATION WAL ,S INTERIOR R— FOUNDATION WALLS EXTERIOR R— -- FLOORS R— -- --- WALLS R_ — CEILING R— ----- DUCT WORK OR PIPING IN —UNHEATED SPACES R_ t �de6C `Ni�G�GGI five l�c� /edde�'lc,rC COMMONWEALTH ELECTRICAL INSPECTION SERVICE,INC. Main Office 357 Elwyn Terrace — Manheim,PA 17545 i(7/0 MUNICIPAL CERTIFICATES - ELECTRICAL APPR VAL Panel Board No. y Cert. 4 50 4 4 Cut-in Card No. Owner I've ct rz.6-CR. 1) Occupant / Location,'3 g7, eh/ -./(,'� --A Installation Consis ofr 1 7CIcy t 2 � f '�—i TES i tiGA-l.14 G E A-DP/ T7ei A Installed By Lic. # The conditions following governed the issuance of this certificate,and any certificate previously issued is cancelled:— This certificate only covers the electrical equipment and installation conditions as of date. Upon the introduction of additional equipment or alterations, application shall be promptly made for inspection. Inspectors of this Company shall have the privilege of maki 'nsp s at any time,and if its rules are vt tatted,the�CP/mpan shall have the right to revoke t c of awca.c.._ Date "` V ! INSPECTOR�..... ...` Member N.F.P.A.,I.A.E.1. d TOWN OF QUEENSBURY BUILDING & CODE ENFORCEMENT 531 BAY RD., QUEENSBURY NY 12804 I i INSPECTOR'S REPORT: ARR1'O 1 DEPAR . °IN REQUEST FOR rIj TION REEEECEIV D NAME �' .r i rQ_ LOCATION l3 g��_ DATE `1 �. PERMIT II r 70� TYPE OF ST CT RE: 01 "�i 8.... RECHECK - APYROVED N/A YES I NO FOOTINGS/PIERS MONOLITHIC POUR FO• REINFORCEMENT IN PLA E THE CONTRACTOR IS RES•.NSIH FOR PROVIDING PROTE TION F OM F EEZING FOR 48 HOURS FOLLOWING , HE •LACE- MENT OF THE CONCRETE. MATERIALS FOR THIS PURPO- ON SITE FOUNDATION/WALLPOUR REINFORCEMENT IN PLACE FOUNDATION/DAMPPROOFI BACKFILL APPROVAL PLUMBING VENT/VENTS :N PLACE ROUGH PLUMBING PLUMBING UNDER SLA: / / G AMING: k V JACK STUD•LHEADERS BRACING/B IDGING JOIST HAN ERS JACK POS ./MAIN BEAM AIR INFILTRATION BARRIER HEATING ROUGH-IN INSULATION: FOUNDATION WA LS INTERIOR R- FOUNDATION WA LS EXTERIOR R- 'I FLOORS R- WALLS R- CEILING R- DUCT WORK OR P PING IN UNHEATED SPACE R- '{totb /14( I 4 0 K 4 ?1 TOWN OF QUEENSBURY BUILDING & CODE ENFORCEMENT 531 BAY RD. , QUEENSBURY NY 12804 �► INSPECTOR'S REPORT: ARR# 1D DEPART-- ` IN REQUEST INSPECTIONPE RECEIVED: (� y- NAME ` `rk 1 1 c c' ACL.-Q-C� LOCATION / 3 cd DATE PERMIT i 9 4" 7/0 TYPE OF STR E: + l RECHECK APPROVE N/A YE = NO FOOTINGS/PIERS MONOLITHIC POUR FORM REINFORCEMENT IN PLACE / THE CONTRACTOR IS RESPONSIBLE FOR PROVIDING PROTE TION FROM FREEZING FOR 48 HOURS FOLLOWING Tt[E PLACE- i MENT OF THE CONCRETE. MATERIALS FOR THIS PURPOSE 'qN SITE FOUNDATION/WALLPOUR sa. tr - -- REINFORCEMENT IN PLACE t- - FOUNDATION/DAMPPROOFING DACKFILL APPROVAL PLUMBING VENT/VENTS IN PLACE ROUGH PLUMBING PLUMBING UNDER SLAB /\ FRAMI_ 5. JACK STUDS/HEADERS ` ✓- BRACING/BRIDGING "'- JOIST HANGERS - JACK POSTS/MAIN BEAM .TI- - AIR INFILTRATION BARRIER HEATING ROUGH-IN INSULATION• FOUNDATION WALLS INTERIOR R- FOUNDATION WALLS EXTERIOR FLOORS R- WALLS— R- CEILING R DUCT WORK OR PIPING IN — - - - - UNHEATED SPACES R- 1 1 )11A\ TOWN OF QUEENSBURY BUILDING & CODE ENFORCEMENT 531 BAY RD., QUEENSBURY NY 12804 .6' INSPECTOR'S REPORT: ARROT UDEPART 49. {i fINT�; REQUEST FOR INSPECTION RECEIVED: al- ' - 4.NAME 2 LOCATION Sir•. . , i- ,I DATE �r '" •- � PERMIT # L; "_ Al TYPE OF STRUCTURE: - 1 a RECHECK r,, - me APPROVED ir N A YES NO I FOOTINGS PIERS 4 MONOLITHIC POUR FORM REINFORCEMENT IN PLACE Till ---__ ---_ ----- ______ THE CONTRACTOR IS RESPONSI:LE Fe PROVIDING PROTE TION FROM REE FOR 48 HOURS FOLLOWING THE MENT OF THE CONCRETE. MATERIALS FOR THIS PURPOSE eir FOUNDATION WALLPOUR A /REINFORCEMENT IN PLACE All FOUNDATION DAMPPROOFING BACKFILL APPROVAL PLUMBING VE_.-___NTwENTS IN PAM ROUGH PLUMBING PLUMBING UNDER SLAB FRAM__ ING_--_ JACK STUDS HE, DERS BRACING BRIDG NGa ______ _____ -- __ JOIST HANGER JACK POSTS SIN BEAMa ------ AIR INFILTRATION BA• •IER _____ 111 HEAT____NG ROUGH-IN INSULATION: ---- FOUNDATION WALL INTERIOR R- .— FOUNDATION WALL. EXTERIOR R- FLOORS WALLS ailli CEILING 111111 DUCT WORK OR P UNHEATED SPAC: TOWN OF QUEENSBURY BUILDING & CODE ENFORCEMENT 531 BAY RD., QUEENSBURY NY 12804 INSPECTOR'S REPORT: ARR DEPAR -'7 REQUEST FOR INSPECTION RECEIVED: 40 NAME LOCATION it, DATE pit - a PERMIT it q -7/a TYPE OF STRUCTURE:\ RECHECK --- -- APPROVED N/A YES A NO //FOOTINGS PIERS MONOLITHIC POUR FORM REINFORCEMENT IN PLACE sii;-/ THE CONTRACTOR IS RESPONS LE FOR PROVIDING PROTE TION FROM REEZING/ FOR 48 HOURS FOLLOWING THE LACE- MENT OF THE CONCRETE. MATERIALS FOR THIS PURPOSE ITE FOUNDATION WALLPOUR REINFORCEMENT IN PLACE FOUNDATION DAMPPROOFING DACKFILL APPROVAL PLUMBING VENT/VENTS ' PLACE ROUGH PLUMBING PLUMBING UNDER S 'B i { FRAMING_,__ JACK S UDS HEADERS BRACIRG BRIDGING JOISi HANGERS JAC POSTS/MAIN BEAM - AIR INFILTRATION BARRIER HEATING :•UGH-IN INSULAR ON: FO NDATION WALLS INTERIOR R- FOUNDATIO_-_ N WALLS EXTERIOR R- FLOORS WALLS R- - - - CEILING R- DUCTR- WORK OR P PIPING IN - -UNHEATED SPACES - R- 94L 7/6 X 23. -/-30. a ?Rop ' Jjo-, R A n)e,1A LC 4 Kr Y 1, r,fzeate.9661 1 I ! .+I rol V) j IF,X/57-/iv 6 i \ •,ft..- Y ES Y. i EYISTa4e It , Oftiu F. f TA, M. f 1 ----f-- ._ _.._— — 1, 29I.5/ /BA Li 1�or?c` Nod r: -;'� !'•r.!7 : 7r, , r •i ./ i TOWN OF QtJEENSBURY c Eu BUILDINC PERMIT NUMBER V illcif.j I �' I - 71O 0 I „...y",,_ a 1. BASIC/BUILDING PERMIT INFORMATION: A i Applicant/Name & Ad ress Agent/Name & Address ` �`' ' -'�-. C� C 1�c� T 13,�1 h p, _ applicant agent ij , W *a tiet '^ xr 1t1ir;'- :lLlre�; Ali'- TAX MAP NUMBER: i 3 R aQo� * / 3 8— ‘2(7rc o-� �oac��s N 2. PROJECT.DESCRI " ��/ �PTION: �' --�' `G I2plot pl n (2 copies) -�--- L-lbuilding plan (2) .c: -.-r, sywage disposal 3. PROPERTY INFORMATION: energy code electrical inspection (driveway permit 4 ET BAC'I.s REQUIRED :.TU:AL. [completed/signed C.-1o' /U A IS:1 FEE PAID Front Yard /oD So /30t ' Front ( if corner) ""..' Side Yard (1) lap 3a ,t,Y/sp.JG f t ❑ NEW CONSTRUCTION Side Yard (2) !vo' ao Wo'f I ❑ ADDITION Rear Yard /06 ' �„ i7c/ */- (� ALTERATION cipd 16a 0 MODIPICATION Depth El YES NO N/A it 'ROPERTY IS IN APPROVED SUBDIVISION tiltiie 4 n Meets depth, width & square footage requirements alp 'reexisting, nonconforming lot with proper setbacks M equired road frontage on public road ' = as required off-street parking tc i0 )84(k IIMM -- Permeable area is adequate / IMMO= 7s •o WM Building does not exceed maximum height / ► ax. roma m ' equired setbacks from stream, lake and/or travel cor i*or meets requirement ism Buffer zones required 111112 Is lot in a Flood Plain Zone? OVER ' 4. STAFF DETERMINATION: 11, As per Sections) ?9�13 of the Zoning CD Sign =.3 Subdivision --( Ordinance Ordinance Regulations 0 112 2 u= 5. REVIEW REQUIRED BY ZONING BOARD OF APPEALS: ACTION FILE NUMBER RESOLUTION DATE ❑ Use Variance ❑ Area Variance ❑ Sign Variance - ❑ Other Comments: 6. REVIEW REQUIRED BY PLANNING BOARD: ACTION FILE NUMBER RESOLUTION DATE ❑ Site Plan Review Subdivision ❑ Planned Unit Dev. ❑ Other Comments: REVIE'hYED B" STAFF DATE COMMENTS �., /// '9 4— YOU ARE HEREBY REQUESTED TO INSPECT AND ISSUE CERTIFICATES FOR THE FOLLOWING ELECTRICAL EQUIPMENT TO BE INSTALLED BY THE UNDERSIGNED t - - CITY OR VILLAGE i - '�., �� 276-/-''. I ZIP CODE COUNTY J/ y� TOWNSHIP / STREET AND NO.OR ROAD ( r`f✓'`:.. +✓:.j �i / `--�- -F, , �^' Bilti POLE NUMBER BETWEEN WHAT TWO CROSS STREETS S PREMISES LOCATED? SECTION BLOCK 14 LOT OCCUPANT'SN f f BUILDING OCCUPANCY OWNER'S NAME AND ADDRESS - /'� ? 'f' f• :- +'"f+� :"' V /38 �'^^�� _ HOME TELEPHONE NUMBER. CURRENT SUPPLIED BY V FROM THEIR OFFICE WORK TELEPHONE NUMBER it 0111,7,0 BUILDING IS NEW❑ OLD❑ I WORK IS NEW❑ ADDITIONAL 511, LIST BELOW ALL EQUIPMENT WHICH YOU INSTALLED DEFECTS REMOVED❑ Loca- NUMBER OF OUTLETS No.of Fixtures& MOTORS HEATERS BRANCH E tion Lame Receptacles ` CIRCUITS Ceiling Side Attach'F H P �1 9 Wall r- al is Switch Pendant Bracket No. Type Each Na Each No. Gaut OUT- 9e - SIDE SUB BASE BASE- MENT : tst 2nd FL d c. 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 SIGNS/LAMPS TOTAL WATTS CHARACTER OF WORK .. ❑ EXPOSED GAS TUBE SIGN/TRANSFORMERS OF VA ❑ CONCEALED DATE WORK TO BE STARTED - DATE COMPLETED SIZE OF SIGN(NUMBER) CAPACITY SERVICE ENTERS BUILDING MANUFACTURER OF SIGN ❑ OVERHEAD ❑ UNDERGROUND DATE INSPECTION.REQUESTED ON(OR AS NEAR AS POSSIBLE) „g. F a ¢.'a �.m kl Al AGCt113A' AU. li�lJtk"1I`„1� t�.AITIpN° �, 4'#.' �e ;' PRINT NAME AND ADDRESS NAME OF APPLICANT DATE OF APPLICATION :� STREET ADDRESS �, r., � TELEPHONE NO. CITY OR POST OFFICE ZIP CODE LICENSE NO.WHEN APPLICABLE © 85 John Street 0 41 State Street ❑570 Delaware Avenue D 217 Lake Avenue ❑ 202 Arterial Road NEW YORK NY 10038 ALBANY,NY 12207 BUFFALO,NY 14202 ROCHESTER,NY 14608 SYRACUSE,NY 13206 (212)227-3700 (518)463-2122 (716)884-1155 (716)254-0141 (315)463-8552 TI4c AM IN. vC D1! Q11A lmn 'NI— rir-ir- . .-