1985-672 i
S
CERTIFICATE OF OCCUPANCY
TOWN OF QUEENSBURY
WARREN COUNTY, NEW YORK
-Aml S LP
Date Apr = = -=- — - t9 %i to
This is to certify that work requested to be done as shown by Permit No.
P r---- F 7
has been completed. C )Y)C 1 ,
This structure may be occup d as a
Location 7::C:T 25 CRC7L? �I CTT 'CTrr ( " t . ''e7 . 6 ) FE�ctiori TT
b 4 V(\C,
Owner 'r r o--Craft I n c
By Order "Town Board
'1`OVVN OF QUEEN38URY
r - f
Building N Zoning Inspector
r
GII<;TMY( 'IN;TA ♦RANTING. GcMN; FALL% N Y T;;pl H1;�9p 3-p;pp
i
Z
CERTIFICATE OF OCCUPAN ." Y
TOWN OF QUEENSSURY
WARREN COUNTY. NEW YQRK
J y 19 `; 6
This is to certify that work requested to be done as shown by Permit No.
has been completed.
1I his structure may be occupied as a
)
Location
Owner
iY;•i L'r1 i.e�i• `� { : 1'.. . 1 _ I' _- l.A`.' E lis11
j i_.,' : % " By Order Town Board
'POW14 OF QUEENS13URY
v _�z �
Building & Zoning Inspector
i
1
C Rl wTWE '"1NST Y4'- /RANTING. 6LEN21 iALLS. N Y 12E61 111E0993-56S■
{
BUILDING PERMIT
TOWN OF QUEENSBURY No. 85_ 672
WARREN COUNTY, NEW YORK
PERMISSION is hereby granted to Fro-Craft , Inc .
OWNER of property located at Lot 25 Grouse Circle ( St . No . 6 ) Street, Road or Ave.
Section II , Pheasant Walk
in the Town of Queensbury0 To Construct or place a One^Family Dwelling ro
I-f
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.
l-i
su
1 , OWNER'SAddressis Peggy .Ann Road
Glens Falls , New York
H
n
2. CONTRACTOR or BUILDER'S Name
same
3. CONTRACTOR or BUILDER'S Address
same 0
Q
rt
IV
4. ARCHITECT'S Name M Un
Fj
Z o
0 G
• to
5. ARCHITECT'S Address fp
rn
C"]
4,I
l7
B_ TYPE of Construction — (Please indicate by X) ~
(U
I ?f Wood Frame i ) Masonry S 1 steel I }
7. PLANS and Specifications
56 ' x36 ' per plot plan , specifications and application
No. submitted including two-Car attached garage and
sewage: system. .
8. Proposed Use
One-Family Dwelling
IWLJ
$ 5 . 00 C/O Paid
$ 192 . 00 PERMIT FEE PAID - THIS PERMIT EXPIRES June 1 19 86 F;
(If a longer period is required an application for an extension must be rnade to the Building and Zoning inspector of the
town of Gueensbury before the expiration date.)
Dated at the Town of Queensbury this 15th Day of November 1985 ~
�
SIGNED BY for the Town of Queensbury t-Q
Building and Zoning I nspector
S
TOWN OF QUEENSBURY (Space inside block to lx• filled ill b%
WARRED COL,(NTYO NEW YORK Building lnspivulor)
AApplication for A,i,11m 1isgl Wit,.
RP YtPrmit sut*tf iq
BUILDING AND ZONING PERMIT Vc,imil F .Rq-oires .
\ jhw id Work
THREE ( 3 ) Copies of a PLOT PLAN, Drawn to scale \I w1 +r , ,. e d 13v
showing the actual dimensions of the lot to be built
upon, The exact slate, and location on the lot of the
building to be erected or altered MUST BE SUB-
MITTED WITH THIS APPLICATION.
TOWN OF QUEENSBUR �
hAtF
A PERMIT MUST BE OBTAINED BEFORE BEGINNING WORK .449 r G iZ
ANSWER ALL OF THE FOLLOWING.
The undersigned hereby applies for a permit to do the following work A 1 ? ice 16
n 1. 23 �4fiFi
which will be done in accordance with the description, plans and specifi-
cations. and such special conditions as may be indicated on the permit. 1,6
The owner of this property is:
{fyA ;�} YP O AObRE555
The person responsible f9r supervision of the work insofar as the Building Code and the Zoning Ordinance apply is:
. . . . . . . . . . . a� + , , . . - .
�r iNAME} IP O A60FSESSy
Name of Builder . . . ./►" r �? . . ��I� . I�l'�.. . . . . . . . . . . . . . . . . . Address . . . . ^ . . . . . . . . . . . . . . . . . . . . , . . . . .
Marne of Plumber . . . . . . . Address . . l r+C rS►- t .G/9 -. . . - . - - . .Name of Mason . - . ,e.i . . . . . . Address . . . . 1- > T . ,, !`i"t. . . . . . . . .
Lot Number . . . . . . t3� �- Unit . . . . - . . Estimated value of proposed work S - - . 7G'� QG'. '�`. . . . . . . . . . . . . .
,► . . . . . . . . . . . . . . . . . .
Nance of Village .
Name of Street . . .C'. { '. . �► .t.. . �I. '��. c— C*:G. . . . . . . . . . . Side of street: north ❑ , east ❑, south @I . west ❑
Nearest Cross Street . . .,r , s� AT—. . it K' . . . . . Distance from this ^-Toss street . . . . . . . . . . . . . . . . . . . . Ft.
Property is north 0 , south (3 , east t.i , west Nfrom. Cross Street
If on Corner, which corner, northeast C i , northwest ❑ , southeast 0 , southwest
(Designate by marking with an "X " in the correct space.►
NATURE OF PROPOSED WORK OCCUPANCY
W Construction of a new building. Main Building
❑ Two-family
Addition to a building. One-family dwelling 0
❑ Alteration to a building. Two family dwelling
❑ -family apartment !rouse ❑
Demolition of a building.
Store building
. . , - - . ..-car attached garage 119
Other: . . . I . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . Accessory Building
One-car detached garage 0
❑ Other work. Describe-. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Two-car detached garage El
Private chicken house 0
. . . . . . . . . . . . . . . . . . . . . . -
Private storage building ❑
Other: . . . . . . . . . . . . . . . . . . . . P . . . . . . . . . . . . . .
ZONING SPECIFICATIONS. Fill in for new building, or addition to existing building, or a change of occupancy.
Indicate on the plot plan street namess the location and
size of the property, the location. shoe and setbacks of pro-
NORTH posed buildings, and the location of all existing buildings.
Show proposed building(s) in dotted line end existing
G-� 5-A f i,1 F} L fC 14uilding(s) in solid line. + 1� ?�
"? X f 5 Y ft.
Size of property . ./. .+ . . . . . , . . . . ft. x . . . . . . .
Size and use of existing buildings, if any
M _ "�aos2 sc ,mac . . . . . . . . . . - - - - - -
, , . . . . . _ . . . . , . . . . . . . . . . . . .
Size of proposed building . . . . . ! . it. x . . . . . G . ft.
Height (from grade to ridge) . . . . . . . . . . , , Z3 . . . . . ft.
Front yard . . . . . . . . . . . . . . . . . . ft.
Side yards . , , . 3 47 . . . . ft. and . . .� . t u . , , . . . ft.
Rear yard
�- SO Y3TH If on corner. setback from side street . . . . . • . . • - ft-
Note : All distances are nest, as measured from street side
line to nearest part of building.
(OVER)
? -73-?l
BUILDING SPECIFICATIONS.,
Kind of construction: Wood frame, fire safe, etc.? . , . . . . . . . . . . . .
Will any second-hand lumber be used? . . . .A' D. . , . . . . . If so, for what? . . . . . . . . . . . . . . .
Material of foundation walls . . . . . C-:~ . . . . . . . . . . . . . . . . . . . . . . Thickness
Depth of foundation wails below grade . . . - y. ./y . . . - . . - - . . . . . . . . . . . . . . . . . . Continuous foundation? _ . . ". . _ _ _ .
Will there be a cellar? . . . . . 1 y. S . , - - If so, material of cellar floor . . . ''.r. . . . . . . . . . . . . . . . .
Type of roof: Sloped or flat? f. . 3LG^ 'C�.p , . . . . Material of roof . . . . . . . . . . . . . . . . . . . . .
Size, wood studs . . . . . . . . . . . . . . . . . . Z x . . . . . Gam. spacing . . . . . . . . _ . /`b� ."'o.c., length . . . . . . . . . . . �' ft.
Size, floor beams, 1st floor . , _ _ . . . . . . Z" x . . . . . . . . . . . ./, V ", spacing . . . . . . . . . . ,/,y. "o_c span . . . . . . . . . . + / ft_
Size, floor beams, 2nd floor . . . . . - . . . " x . . . . . . . . . . . . /-P , spacing . . . . . . . . . . . "o.c., span . . . . . . . . . . .
Size, ceiling beams . . . . . . . . . . . . . . . . . /!�U- S' . . . . spacing . , - . . , - , . . "o.c., span . . . . . . . . , , .Z ft.
Site, roof rafters or beams - . . . . . . . . , . " x . . . . . . . ", spacing . . . . . . . . . . . . "o+c., span . . . . . . . . . . . . . . ft.
Exterior finish . . . . . . . . . fr!�!1 �c�r With whg4 material? . I- !;- . . . . . . . . . . . . . . . .
Finish of interior walls . . . . . . . 4010
+ l /�' - - • • �`• G"`�
If garage is to be attached, of what material is wall between garage and main building to be constructed?
-7.1 e! C 4�. . . . /T,t �`L` . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • -
Is there to be an opening between garage and buildingil tr- -57 a . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Kind of heating system . . . . . . . . . . . . .1 77 fe4 •M.f.. Oil burner or coal? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Will a flue-lined chimney be provided? !. . Y� . . . . . . Depth of chimney foundation below grade . . 3" . . . . . , .
Height of chimney above roof. . . . , . . . . . . . . . . . . . . . . . . . . . . . . .t . . . . . . . . . . . . _ . . . . . . _ . . . .
Will there be a fireplace? . . . . . �V G '- . . . . . . . . . . . . . Depth of fireplace hearth . . . �'c- . . . . . . . . . . , , , , . . . . . .
Willa toilet be installed? , . . . . . .Y4t 3, . . . . . . . . . . . . '. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Will a kitchen sink be installed and connected to water suppl ? . . . .x!` _5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Water supply (public water supply or pump) . . . . . . . . 'JJ Kic . . . . . . . . . . . . . .
Distance of cesspool from any private well . . . , , , - , , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , , . - , . . . . . . . . . . . . . . . . . feet
Will drainage system be provided with required traps, cleanouts, and vents? �3 `� r
Town of Queenshury AFFIDAVIT
County of Warren
State of New York
I swear that to ti lhrj r of my know,tedge and belief the statements contained in this application, together with the plans and specifications sub-
rained, are a true and co fete ataternent of A proposed work to be done on the described premusea and that ■ of the BUILD-
ING CODE, THE ZONING ORDINANCE, and all other laws pertaining to the proposed work shall be compficd with, apeeified or not,
and that such work is authorized by the owner. Q /` _�
Swam to before me this Signature . . .. . . . - ' . .f. ' ! �".'�„"� ../. ..� .?... . . . . .
gWNE'R, QwNER"5 A t:NT, aRCHvfEGY, CpwTR/�CYpR
day of. . .. 19i/y�]..^�-
NOTARY PUBLIC, WARREN COUNTY, N. Y.
SPECIAL CONDITIONS OF THE PERMIT,.
By .. . . . .. . . . ..... . . ... .. . . . ..... . . . . .. . . . . . . .... . . .. ... . . . .. . . . . .... . . . ... . . . . ....
TOWN OF QUEENSBURY
WARREN COUNTY , NEW YORK
Application for : BUILDING PERMIT IN COMPLIANCE WITH THE NEW YORK
STATE ENERGY CONSERVATION CODE
A permit must be obtained before beginning work .
ANSWER ALL of the following :
1 . Gross floor area 7�_-5� 0 7
2 . Type of heat , f
3 . Is the building mechanically cooled ?
4 . Percentage of area of windows and doors
A . Over 16 % Only
1 . Uo value of gross area of walls , roof/ ceiling and floors
exposed to ambient conditions
2 . Floor over heated spaces YES NO
a . Ave foundation walls insulated ? YES NO
1 . If YES , what is the R value ?
3 . Slab on grade YES NO
a . If YES , what is the R value of insulation around
perimeter of floov ?
4 . Is basement heated ? YES NO
a . R value of insulation
5 . Type of insulation
n . 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 f , :;;r
4 . R value of doors � .
5 . R value of floors over unheated spaces
6 . R value of slab edge insulation - unheated slab -v
7 . R value of slab insulation - heated slab
8 . R value of heated basement /cellar walls ( above grade ) �+ / ^
9 . R value of heated basement/cellar walls ( below grade )
10 . Type of insulation_ ! T G.�g S� I,-' -� 7--7--i--
C . Controls
1 . Thermostat maximum heat setting
D . Duct Systems
1 . Is duct system installed in unheated spaces ? YES NO
a . If YES , R value of duct installation ,g ,
b . R value of duct in other areas
E . Piping insulation
1 . Size of hot water or cooling carrying agent pipe
2 . R value of pipe insulation 7
F . Service Water Heating r I
JF
1 . Performance efficiency- S /
2 . Temperature control setting maximum.. .
G . For Swimming Pool Only } -
" 1 . Maximum
a Max -imum umheating
Telephone No . ! � U �S -�`y`'-
( applicpOr►'��t ' s signature
+
TOWN OF t7UEENSBURY
BUILDING & ZONING DEPARTMENT
SEF?AGF DISPOSAL PERMIT APPLICATION
1 . Owner ' s Name. 00e pL f / �
Address 0 ,.�'!�
Telephone Noe
ram'.? 3
2 . Property location d ' '! ,�2 ,�'dL/ e"Z e7 e7 / � rii'iac. ] rs �u
3 . Name of person or firm responsible for installing system
e,+ , L''� � i Telephone No . 79 r33
Address
4 . Number of bedrooms ( residential buildings only)
5 . Daily flow gallons/day
6 . Septic tank capacity 44t5p,p p c :gam- gallons
7 . Topography : flat rolling , steep
$ of slope
80 Nature of soil and depth •''`-
9 . If ground water , bedrock or impervious material is apparent at what
depth does it begin? ft .
10 . Percolation test : A is recxulred
B is not required
C If required what is the rate minutes/inch
11 . Water supply : municipal , well , other AV G.,'r Cr /.�'G
12 . Type of system proposed : drywell , le fie 'other
Any contractor , corporation , individual , etc . engaged in ' -the construction
of a sanitary sewage disposal system who covers the same before inspection ,
does not have an approved permit , or varies from the approved application
will be subject to a penalty of $ 250 as provided for in Section 6 . 010 of the
Queensbury Sanitary Sewage Ordinance .
Date_ Al . s.� . -
sIgna :,fir off, Opp c t
On separate sheet of paper submit a diagram of the pro osed septic system
with all dimensions , including distance from any structure , distance from
property line and domestic water supply , etc . Include all dimensions of
the system itself .
Form 3 - 82
w
TOWN OF QUEENSSURY
Sailding- Department
Name C-s�r
L.ocaii m W,ea►ther
Permit No*
r"1 rG 4L jk)Z) 4 Remarks
MEN
sxcaoation
Foat.in Forms
Faatin & Piers
Foundation
Cement Coat
Water roof-in
Raakfill
Final curve
Framin
Sheath-in
Roof Felt JL
Roofin D l
si.dan
Masonr veneer
Rau h p1baft �
Relief valves
Wall Board
Ext . Porches
Finished Floor
interior Trim
stairs & Railin s
Ce] Iar Dr , Tile
Concrete Floors
pl . Fixtures
Gar . Fire raafin dl
Dtrpr Closers
Ch-i mne
Water Meter inst .
Se tic A royal
Floors � —
FDundatiyn --
insulation Walls
eilin
Buildings i spectar
R.EMA22Kar"
C91�--
NEW Me
4057381 THE NEW YORK BOARD OF FIRE UNDERWRITERS
BUREAU OF ELECTRICITY
41 STATE STREET. ALBANY. NEW YORK f2207
a Ee Application A'o. ore fife
THIS CErll i )+ ,f3' 21V 1986 103910 - 85 � � ,�� � � � �1
F�
only the electrical equipment as described below and introduced by the applicant named on the above application n6umber in the promises of 6
Pro-Craft onstruc on Co 25 Grouse Circler Glens Falls , New York
in the follaasing location; � Basement � lot FT. $red Fl. Outside Section Bloch Lot 2 Jr.
was examined on 1 f 1 7 / 86 and found to be in compliance with the requirements of this Board.
KXTLMN FIXTURES RANt3ES COOItING DEC" GIVENS DISH WASHERS EXHAUST FANS
CMJTI.LTuS ACRES SWITCHES IM[ANOe$[ENr F1L1011E8CtlFi AMT. K- W. AMT. K_ W. AMT. X.W_ AMT. K. W. *.MT_ H. P.
FR
DRYERS ]FURNACE tAOTORS FUTURE Apru^mcii DEERS SP00AL REC'FT TIME ewcots an" UNIT HEATERS MULT14X HM
------
AMT. K. W. Ole H. F. C.AS H. P, AMT. NO, r�A- W.yG0, AMT. AMP. AMT. Aws, fRAN19 AMT. T r. S'.'<0 M wMT. wh1T5
ang e J 1 NO. OF FEET
SERVICE DISCONNECT NO. OIL E R V 1 C E
AMT. AMP. 77'P'E METE
Rj 1 ,0 2W 1 jr sw I a X JW 9 X 4w I NO. cIF CC. cgMD. A. W. G. No Or HI•Leo A. W' C'' NO. or NEUTRALS A. W.
PER I OF Cc. COND, OF HI.Len. OF MFU AI
200 CB 1 I x I 1
OTHER AMARATUfe
1 -- G . F . C . I . Electric Heaters : 3 - 2 . 0 kw
1 - Smoke Detector 4 - 1 . 5 kw
2- 1 . 0 kw
2 - . 75 kw
07
Birch
Electric Co . � 7"�-ff}}
/-" BirchLaneE1NtANCH"AIANAGER
Glens Falls , New York 12800
Par
This certificate must not be offered in any manner. return to the office of the Board if incorrect. Inspectors may be identified by their credentiak.
COPY FOR BUILDING DEPARTMENT. THIS COPY OF CERTIFICATE MUST NOT BE ALTERED IN ANY MARINER.
ve,artuloot
v � -7 l�
NLOCUUM IIIAI
= " ;N
Perms No.
Excai7a t-1 on
Food m
Fors
f� ri . Piers
Foundation
Cement Coat �---��
Water roo ......Final Surve --�"
Frau+ln
thWIN
in
Roof Felt
Roofln
Siding r---er
�r veri
h PI
you Valves
R
` elief
e Board
} al , Porches
Ext Finished Floor
interior brim
Stairs Rail n 5
Cellar Fsr . Tile
Concrete k loors
Fixtux�s
1 Gar , Fire roof in
Poor Closers
Chimne deter Snst ,
-- - W�t ti roval
A F1. S
Found ri
Insulation CellinLA 21— �—
ctor
1 13U lding InsPe
REMARKS _
l 12L& L 1 t
Is �}
i �' f 'Et4semy
.T,OWItt Orr C D
g.,wit,din= D+sfiurtm►+ent
Date / L
i, ra 111 Rat 11, 111
Ttatoe C s wr
1t*ewmam - RejDa rks
FooExcai7��gores
tin & piers
Footin lon
Cent Coat
ofixi
Sacicf ill
Final. Surve
Fxa�-n
Shy-"athin
Ro,of Belt
RoOfl
—�� siding veneer
,asonr pl
R,ou h valves
Belie Board
wawa ll
Ext - perches
hed Floor
s Trip+
Sntex xo& Bailin S
Stairs Dr - Tile
Cellar F
2loors
Concrete f ixtures
p xoofin
Gar - gire
Door Closers
Ch�wailone .
ter al
Se tic A rov F oor dn
Foundat
wall is
insulation Ceil .
Braildin insPector
t 1C3 „� 1J fwD ID t7 x!S
72 Q F}Gi
fo1 (T VVV
Oyt,-
ToWt4 or, cpJEEMISS RY
two
pown3it Ed
r
Names _.
Remarks
gxcatra txon
Foot ra Form
Food» & Piers
Forandation
Cent Coat
wetter fin
ae�gill -
Final Surv,
pramin
shoatta
Roof Felt
Roof!
Si+din
Masonr Veneer
Rou h PI
Relief Valves
Wall Board
S29 t . Porches
shed Floor
.nter iox Trim
stairs & Railin s
Cellar Dr , Tile
Concrete Floors• -
�,I Fixtures
G, r • Fire roofin
Door Closers
Chimne meter Ins Water M .
eptice rove]-
Foundation - -- �-- -_
Ynsulation Walls
0121
to,
ul
dingy snspe,otor
REMARKS
O,r-1, ro I
Y3 0K-
� 4DO ��
Ut- !`-�
Irpi11 N OF CIUEE14S BURY
N&J
Locukleft
PON - not
Rerna r s
SxcaV8 t on
Footin Forms
Foots & Piers
Foundation
Cent Coat
Water roofin
Backfil2
Fjnal Survey
Framin
�ieathin
Roof Felt
Roofln
Sidiri
masonr veneer
Rpu h PI -
Belief valves
Wall Board
Sxt . Porches
trinished Floor
Xnterio& Rax1n 6 IS
Tile
Cellar Dr -
4^OnCT�ete Floors
PI Fixtures
Gar . Eire roofin
Jill 1C Closers
Chimne xnst .
Water Meter
Se tic A rove]
FIOdrS
poundar.I.I �-- --
Xnsulation Walls
i.1in
Buildin Xnspector
R�r�y,RKS
TowN of QUEENSSURY
81111aag Department
LACMdow
Pernik NO* G � - jI 07 W anther
Remarks
8xcatYat-ton
Food Farms
Footin & Piers
Zrar elation
Cement Coat
Water roofin
Backfi1l
Final survey
Fratni
Sheathin
Ftaof Fel t
Roofin
Sidi
Masonvu veneer
Rou h PI
Relief valves
Wall Board
Ext . Parches
Finished Floor
Interior Trim
Stairs 6 Railin S
Cellar pr . Tile
Ca,ncrete Floors
Pl • Fixtures
Gar . Fire roofin
Doe3r closers
Chimne
Water Meter Inst .
Septic A roval
Floors Foundation
Insulation Walls ---� �-
Ceili�
Building Inspector
REMARKS
TOWN OF QUEENSBURY
Building Department
lnepmctyam Repeeet Date 10
l aata►t ioirt L.- O S
Aff
PeetiR No. Wcstlaer
Reniarks
8xca0ation
Footin Forms
Footi & Piers
,Foundation
Cement Coat
Water roofin
Backfil2
Final Surve
Frarain
Sheathin
Roof Felt
Roof in
Siding
Mmsonrw veneer
Rota h P2
Relief valves
IIIIIIIIIIIIxIII
Na Board
8xt , Porches
shed Floor
Interior Trim
stairs & Bailin s
Cellar Dr . T32e
Concrete Floors
P2 Fixtures
Gar . Fire roofin
Door Closers
Chicane
Water Meter Inst .
Se tic A royal
Flaors ...
Foundation
Xnsulation Walls
Ceiling
1,. IA i !A.
-
uilcSxng Inspector
REMARKS
BUILDING DEPT, COPY OF APPLICATION FORM 464EL, NEW YORK BOARD OF FIRE UNDERWRITERS.
FILE THIS COPY WITH BUILDING DEPT. WHEN RECHARED.
TEi1Ft & DATECITY OR
VILLAGE / �- �
STREET AND NO OR TOWNSHIP �� +yr COUNTY
ROAD AND POLE NO
CROSS STREETS ISS ■ ,I POLE ND.. _
PREMISE L TED7 -� _. R 7� riJ e A '-
OCCUPANT'S SE TION BLOCK LOt c"'
NAME�Oe, — BUILDING _
OWNER'S NAME OCCUPANCY / �- ,fjl,/Y►
AND AODR ESS C�
!" TE L. #
SLIPPLIED
Adz Z
BUILDING r -� FROM THEIR - f�
OFFICE
IS NEW OLD ❑ )WORK NEW OE FELTS f-�
AODITfONAL
LIST BELOW ALL EQUIPMENT WHICH YOU INSTALLED REMOVEDQ
NUMBER OF OUTLETS No_ pf Fixturaa A,Lots- Lamp Raceptealy MOTORS HEATERS BRANCH
Like" CIRCUITS OFFICE USE
Co"hrp Side Attac.•t ONLY
Wall Recrp'I& Switch Pendent Bracket NO. Type H.P. E1hla No. a W.G.
each No. auga INSPECTION
ssiidde
Sub-
base
Been.
manx
Tat Fl.
2nd FI.
Skd FI.
REMARKS: LIST OTHER ELECTRICAL DEVICE'S NOT SET FORTH ABOVE:
DO NOT USE THIS SPACE.
This application is intender} to cagier the shove-liifed equipment to bs inspected but if at time of i
You are authorized to make the :klaPection and adjust the fee to cover the additional napettion there K found additional equipment not above listed,
SIZE OF equipment, as provided by the applitant_
MAINS ,er 014 . FEEDERS ELECTRIC SIGN TOTAL
CHARACTER LAMPS WATTS
OF WORK EXPOSE GAS TUBE SIGN
'WO CONCEALED WORK TO BE TRANSFORMERS OF VA
STARTED COMPt.ETEO (NUMBER) (CAPACITY1
SERVICE OVERHEADUNDERGROUNDSIZE OF SIGN
ENTERS
B ILDING MAKER
INSPECTION REQUESTED OF SIGN
ON OR AS NEAR AS
POSSIBLE
NEW � OLD
AVOIb DELAY BY GIVING FULL AND ACCURATE INFORMATION. ALL SPACES MUST BE FILLED IN OR APPLICATION MAY BE RETURNED,
PRINT NAME ANDr �yADDRESS
AOF
PPL CANT iJ a +�
�r i DATEOF
fCATION
STREET ADDRESS _ / !rj k' { /�J G ,!= + J `_ TELEPHONE # _ �`/ � f ��CITY OR ,- � r
POST OFFICE 7 _ ZIP L.� LICENSE NO.
CODj/ WHEN APPLICABLE
na E� CReV. ,,rsel A SEPARATE APPLICATION MUST BE FILED FOR EACH SEPARATE BUILDING
+„-� f 'S„'!" f 4.� r is y " a � � �� � � 55r �K'L�:" ��..?' '� '.�3y�•1(.,��rx'
1 SJ,7➢. H.ej+'i r $ �' � �t w � � x�iP t �"'{rq- �Fc i'1`" �/ A ^ i. �3.: d� .y� .�i� ?,.,:' k ��F /�' r � � 4�� 1�n•, 3. . . w
f(.T
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uik
(1 'AD
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