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1987-171 { i ti s'"r i l � t CERTIFICATE OF CXCUPANCY TOWN OF QUEENSBURY WARREN COUNTY. NEW YORK Feb a 1923 Date February i , 1988 ,t lLD -- 11 � ?his is to certify that work requested to be done as shown by Permit No. 87-171 �I has been completed. - 11 This structure may be occupied as, �)I'a-Farm 1 Awe 1# €i g; Cy Location of 3J. V Drive Stonehurst Subdivision Owner WWLM and thy Weaver By Order Town Board TOWN OF QUEENSBURY 1 Building & Zoning Inspector i d I BUILDING PERMIT TOWN OF QUEENSBURY No. 87-171 WARREN COUNTY, NEW 'YORK PER MISS10N is hereby granted to Wm . and Cathy Weaver w OWNER of property located at Lot 31 Thistlewood Drive Street, Road or ,Ave_ p Stonehurst Subdivis3On in the Town of Queensbury, To Construct or place a One-FaintlyDwellin p' rt 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. ro w 1. OWNER'S Address is 2102 Regency Paris. ApartmentsCD Queensbury , NY 12801 2. CONTRACTOR or BUILDERS Name same t~ 0 rr w i— 3. CONTRACTOR or BUILDERS Address r] same w r n m 4. ARCHITECT'S Name fl d G�. V rt I-� d 5. ARCHITECT'S Address ro r. to rt O ro 6. TYPE of Construction — (Please Indicate by X) Mu tits ( Wood Frame ( I Masonry I ) steel I I mrt 7. PLANS and Specifications 64 ' x26 ' per plot plan , specifications and application including ' No. sewage system and two-car attached ,garage . g �v S. Proposed Use One-Family Dwelling Y I� $5 . 00 CIO $ 157 . 00 PERMIT FEE PAID — THIS PERMIT EXPIRES November l 1g 87 ro (If a longer period is required an application for an exterision must be made to the Building and Zoning inspector of the ~ N- town of Queensbury before the expiration date.) Dated at the Town of Queensbury this 17th Day of April 19 87 SIGNED BY �_ for the Town of Queensbury Building and Zoning inspector _ TO BE COMPLETED BY BLDG . DEPT. � Application No . 7ou/n o f QueeMt3G+/ ury Permit Issued 19 "COVVIN OF �LfE�iVSBL BUILDING and ZONING DEPARTMENT Permit Expires 19 ! Bay and Haviland Road, R.D. 1 Box 98 Zoning Designations Glueensbury, New York 12807 Variance No . 1 Site Plan Rev ew No . i APR 151987 7 7" Approved jr L BUILDIING & C DE DEP-. >APPLICATION FOR f q90 S BUILDING AND 70N I NG PERMIT A PERMIT MUST BE OBTAINED BEFORE BEGINNING CONSTRUCTION . ANSWER ALL OF THE FOLLOWING . The undersigned hereby applies for a Building Permit to do the following work which will be done in accordance with the description , plans and specifications submitted, and such special conditions as may be indicated on the Permit . --r The owner of this property is : WiR 1 ( 1,60K1. C/ 2 "ae:, e P . U. Address �P4, td {� Tel . Property Location : Zcir '0 3 1 !i�J yh-e► �eL S`t'orvnn y� Tax Map No . Street number or building lot number Subdivision name (if applicable) 'r'+a y..) F It t =� THE PERSON RESPONSIBLE FOR SUPERVISION OF WORK AS REGARDS BUILDING y �CODES IS : � Name P . O . dress n 7{{ � I Tel , No . Name of builder (21it'MAC ° ,d ress S '7lcrZw°25Ut v+ . Tel . $ 1 ' - (jt1� KZo? 9 Name of plumber -Vff-)b nfS- Address ccane) {�S�Tc. ' ).. IJ pr , Tel . ; ' Y- 66f- e F?, Name of mason77gj-11 ( e}fC{� HSYd J{ fit• Address � '_ g2pd —Tel . CR et o 6 4 t4k4. (Pj% NATURE OF PROPOSED W RK : ZONING INFORMATION : _Construction of a new building A PLOT PLAN MUST BE PREPARED AND SUBMITTED , Addition to a building drawn reasonably to scale and attached hereto , _Alteration to a building showing clearly and distinctly all buildings , (no change to exterior dimensions ) * whether existing or proposed and indicate all Other work (describe) set-back dimensions from property lines . Give r street and number or lot number and indicate whether interior or corner lot . Show location FOR DEMOLITION PERMIT , STATE SIZE AND * of water supply and location and configuration LOCATION OF STRUCTURES AFFECTEDw of septic disposal area . * COMPLETE INFORMATION REQUIRED BELOW . / Size of property $ ft X c�ft ( 1. 7,6 Acte Existing building ( s) Size ft PROPOSED BUILDING AND USE : Existing buildings ) Use Size of new structure -ft X� Foundation-pier/slab/crawl/partia (full Proposed building , distance from property line (circle one ) Front yard £t Rear yard l ft �"1P '-' , No . of stories (habitable space) Side yards < ft and . ft Height ( grade to ridge ) _ o� D flP �A ft • if on corner , setback from side street sd f2 ft If residential , no . of families No . of rooms ( excluding baths ) 8 OCCUPANCY INFORMATION No . of bedrooms mot` PRIMARY BUILDING - No . of bathrooms r/C7ne family dwelling Primary heating system Two family dwelling Type of fuel_ to f . * Multiple dwelling / Number of units No . of fireplaces to be installed- -�,ermanent occupancy Will a wood stove be installed? /V Transient occupancy Central Air conditioning? N G7 Business BUILDING STYLE, PRIMARY STRUCTURE Industrial Ranch Contemporary Log cabin Other If addition, what will use be? Raised ranch Mansion Duplex Split level Old style Bungalow Cape Cad Cottage Other ACCESSORY BUILDING- olonia Row Town House Detached garage/one car/ t car/ car { CIRCLE ONE PLEASE ) �ttached garage/one car two ca car Private storage building ESTIMATED MARKET VALUE OF * '-Other CONSTRUCTION s - /; . . . . . . . . . . NFORMATION ON BUILDING SPECIFICATIONS , ON REVERSE SIDE OF THIS SHEET, TO BE COMPLETED ! m BPA 4/86 and-vl BUILDING PERMIT APPLICATION CONTINUED - BUILDING SPECIFICATIONS : Type of construction , wood frame fire sa€e . etc . Will any second-hand o nur gra ed lumber be used? If so , for what ? - � Foundation wall material CC) +`iGfL �'� �i Thickness {� Depth of foundation below grade (to bottom of footing ) Pe�_ _{ Will there be a cellar? Heated or y pheated? Floor sqo footage sq ft (y,Pea ) Will there be a basement? Will an or ion be used as living space ? 1 ( If so , what portion? sq . ft . - pe of use? ` Type of roof - sla e flat/shed/other Material of roof Size , wood scuds Z "X_ _ " spacing"o . c . length _ _ft . r Joists ( floor beams ) lat . floor ��„X Q spacing_„/{"o . c . span � � ft . ,Joists ( floor beams ) 2nd . floor "X�" spacing_ ,��"o . c . span�`ft . - ., . c . spanRoof SpRe"q _ Roof trusses (pre-engineered) spacing 24-"o . c . span�ft . , / Exterior wall finish �f , y% pf �yt material? G'/Jl/j/z Interior wall finish ls- ", y,,ryne y �Ji� _A 4 r } rg If a garag is to be attached , describe materials to be us for IRE SEPARATION : Ce Is there to b an opening between garage and dwelling? If so will a Fire-rated door , enclosure , and self-closing device be provided? IV CARO e Will a flue-lined chimney be installed? 57S Height above roof. ft . /V F-PfA -2I � Depth of chimney foundation below grade ft . Water supply - Municipal or private well �/lydi SEPTIC SYSTEM Distance from ANY private well ( including adjoining properties / 57 ft _ P) (A separate application is necessary forfor any �rreprair or new installation of septic system) Town of f Warren A F F I D A V I T STATE OF NEW YORK County of Warren I .swear that 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 provisions of the BUILDING CODE , THE ZONING ORDINANCE , and all other laws pertaining to the proposed work shall be complied with, whether specified or not , and that such work is authorized by the owner . SWORN TO BEFOXR ME THIS Signature _Z!f,�2 day of � Cheer , owner ' gent , arch ^ ect. contractor '., 19 Notary Public , Warren county, N . Y . SPECIAL CONDITIONS OF THE 'PERMIT : 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 2 . Type of heat L01 4 66 3 . Is the building mechanically cooled ? VVVVVV /VD 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 . Are foundation walls nsu1ated ? YES NO 1 . If YES , what" is he R value ? 3 . Slab on grade � NO a . If YES , what he R value of insulation around perimeter of ox0 4 _ Is basement hea ed ? YES NO a . R value of insulation 5 . Type of ins ati. on B . Under 16 % Only I . R value of roof and floors exposed to ambient conditions. 2 . R value of exterior walls ? — ? 3 . R value of glazed area a ,+ _ 4 . R value of doors ^� :5 ' / 5 . R value of floors over unheated spaces ' 6 . R value of slab edge insulation - unheated slab 7 . R value of slab insulation - heated slabu� 4 S , R value of heated basement/ cellar walls ( above grade ) � 9 . R value of heated basement/cellar walls ( below grade ) J 10 . Type of insulation 'Jt t/5 �Gr1kg. Foe' �� J C . Controls ° 1 , Thermostat maximum heat setting Q p . Duct Systems 1 . is duct system installed in unheated spaces ? YES �� NO a . If YES , R value of duct installation b . R value of duct in other areas E . Piping Insulation p 1 _ Size of hot water or cooling carry ' g agent pipe 2 . R value of pipe insulation F . Service Water Beating 1 . Performance ef £ iclency 2 . Temperature control setting maximum G . For Swimming Pool Only 1 . Maximum heating Telephone No . ( applican s signatu e ) APPLICATION FOR SEPTIC DISPOSAL PERMIT DATE _ ZZ, / LOCATION OF PROPERTY FOR INSTALLATION L IM- 3 ! 7T41 SPCUiW4 VyP - ` {' 0996A�5 Owner's Name: ! �j idl k VT7 1fr� 1W 6-1q UC Telephone: _1 ) ' — �i '�` 9 1G c sAddress: � ._ 6 # F . azFro ► Installer`s Name: 'Bill 1,4kg O,L SyauGl�7pyY Telephone: Number of bedrooms (residential only) ,r/-yr� Total daily flow (compute Ca150 gal per bedroom) � [7 OO c101 Topography: circle one: Fla Rolling Steep Slope of slope T Soil Nature: circle one San Loam Clay Other J Depth: _ feet I* Ground Water: At what depth? feet e Bedrock or Impervious Material: At what depth? feet Percolation test: circle one: not required [!require / rate min. inch. Domestic water supply: circle ones Municipal Well ther IF domestic water supply* is a Well: <- Separation: Watersupply from Septic absorption _ / feet PROPOSED SYSTEM : Septic Tank p{UfIO . gal. (minimum size: 1,,�000c0 gal.) TILE FIELD: Each Trench feet / Total system length ic9 feet Size of stone to be used # Z / Depth or Thickness �� feet VV! I . IMPORTANT` ...Please...LIST NEW EQUIPMENT TO BE INSTALLER (over) Section II Septic System Inspections: A. All applications for septic system installation, alteration or repair, as required by the Town of Queensbury Sanitary Sewage Ordinance, shall be submitted to the Building Department at least 24 hours before start of construction and shall include a plot plan showing: 1 .) the proposed location of the system 2.) location and distance to lot lines 3. ) location and distance to structures 4.) location and distance to any water supply 5.) size and dimensions of all tanks, distribution boxes, tile fields and/or drywells B. No system shall be covered before inspection and approval by the building Inspector. Failure to comply with this requirement may result in the uncovering of the system by the installer and a fine of up to $250.00. c. An approved copy of the plot plan shall be available on the construction site. Failure to produce said plot plan at time of inspection may result in an immediate work stoppage. D. Should unforeseen problems during construction prevent proper installation, alteration or repair of an approved system, a new proposal must be submitted to the Queensbury Building Department before further construction. I have read the regulations above and agree to abide by these and all requirements of the Town of Queensbury Sanitary Sewage disposal Ordinance,. Signature of responsible person: VL Date: s Town of Queensbury Building and Code Department Bay at Haviland Road Queensbury, New York 12801 (518) 792-583 2 SETTLED 1763 . . . HOME OF NATURAL BEAUTY . . . A GOOD. PLACE TO LIVE �, t4 "lawn o ueen36urt�t y , ` f� BUILDING and ZONING DEPARTMENT / Bay and Hate+land Road, R.D. 1 Box 98 {7 Queensbury, New York 12801 BUILDINGINSPECTOR ' S REPORT NAME LOCATION �7G �e' f�/7l/ � /r�"� ►✓ +9 Date Dateel 9 permit Now // T APPROVED - YES NO Footing/Fier Forms Foundation Waterproof ng - Backfill Framing � Roofing Siding Masonry Ven er Rough Plumb' g Relief Valve Ext . Porches Finished Floor Interior Trim Stairs rk Railing cellar Drain Tile Concrete Floors v _ Flbg . Fixtures Gar . Fireproofing v Door Closers Smoke Detectors Chimney INSULATION : Foundation Floors Walls Ceiling FINAL ELECT ICAL INSPECTIDN_ .IDRIVEWAY AP ROVAL ild ng Survey Next scheduled Inspection (call when ready ) Remarks- Building Inspector 6/86 and-vl THE NEW YORK BOARD OF FIRE UNDERWRITERS BUREAU OF ELECTRICITY NLG 41 STATE STRE ET, ALBANY, NEW YORK 12207 Date AP'RIL 19 P 1988 Application No. on file 009185 /87 A 71314 6 THIS CERTIFIES THAT 1 only the elecErical egeslpmerst as described belosc a+sd introduc ad by the applicant nonsed o n the above application number in the presrtis" of WILLIAM J . WEAVP.R, LOT 31 THUSTLEWOOD DRIVEr QUEENSBURY , NEW YORK in the following location; E:i Basement Ek$st Ff. ❑ AVnd Fl. OUTSIDE Section. 54 Block 7 Lot 31 seas examined on 1 l L G / r3$ and found to be in compliance with the requirements of this Board. FIXTURE ACLES SWITCHESFI1}C1'IJRES RANGES COOtftNG DECKS OVENS DISH WASHERS EXHAUST FANS OUTLETS MCS" INCANDtSCENT[ FLUORESCENT AMT- K. W. AMT- K- W- AMT. K-w. AMT. K. w. AMT. N. r- 28 56 23 1 6 . 3 3 eR DRYERS FURNACE MOTORS FIXTURE AppUANCE mDERS SPECIM RRCOPT TIME CLOCKS BELL UNIT HEATERS M f T��TU1q DIIAIsi] AMT. K. W. OIL M- F. GAS H- F. AMT. NO, G. AMT. AMP, AMT. AMPS. TRANS. AMT. H. F. No. OF pW AMT. WATTS RY O 1 I DRYE # 10 SERVICE DISCONNECT NO. # S E It V C E AMT_ AMP. TYFE MEaUIP. I x 2w 1 AT 3w S Xr 3w 3 w sw -NO' OPERCs,CONb. OF CC C014D. �" - "I-Leo NC. Of NEIITRAlS Of NEUTRAL 1T�AL rd 1 200 CB 1 1 4 /0 1 2 /L7 OTHER APfARATM ,. L'LECTRI C ROOA HEATERS 3- 2 . 0 K14 ' 50 1 . 5 KW 2102 "GENCY PARK G ..ENS FALLS , NEW YORK 12801 BRANCH MANAGER r PerIft . This certificate must oat be altered in any manner, return to the office of the Board if incorrect. Inspectors may be identified by t r credentials. COPY FOR BUILDING DEPARTMENT. THIS COPY OF CERTIFICATE MIST NOT BE ALTERED IN ANY MANLIER. .}owr+ okeerr � etrr BUILDING and ZONING R PAR RTME 9fd Bay and ViSviland Road, Clueensbury, New York 1280� BUILDING INSPECTOP' IS REPORT NAME I LOCATION Permit n r N0 0 d fn C f ���"" Date_=_LI1�-- * * * * * * * * * � APPRpVED* - YES i30 Footing/ Pier Forms Foundation waterproofing Backf ill j..?�raming Roofing Siding Masonry Veneer Pll=binc3 ~-~ Bough Belief Valves_ Ext . Porches Finished Floors Interior Trim Stairs & 'Railings cellar Ara in Tile Concrete Floors Plbg . Fixtures Gar . FireProofi Door closers Smoke Detecto Chimney IN S[3LATION Foundation Floors Walls Ceiling —� ~- CAL IL3SPECTI(3N FINALL E TRI DRIVEWAY APPROV Survey Final Building Next sctseduled inspection (call when ready FLemarks- p uildin9 Insector 6/86 and-vl S� /�}zeeen6eere� flown a� `�aC BUILDING and ZONING DEPARTMENT gay and Haviland Road. R.D. i BOX 98 oueensbury. New York i 280i BuI LDI NG INS/P' ECTOR ' S REPORT NAME LOCATION Q74 f Date Z 14z � FBFmzt No . * * * * * * * * * �* * APPROVECI* - YES* I3 *NO rooting/Pier Farms Foundati-O Waterproofing Zck.f i_l l naming Roof In Siding Masonry Veneer yeT'iough Plumbing Relief Valves Ext ,, Parches Finished Floors Interior 'Trim Stairs & Rallings Cellar Drain Tile Concrete Floors plbg Fixtures Gar , Fireproofing Door Closers smoke Detectors Chimney INSULATION Foundation Floors walls Ceiling .-- FINAL ELECTRICAL INSPECTIC�N�� DRIVEWAY APYROV Final Building Survey-�-� e Next scheduled in �pectfon (call ready when Remarks- 67 WAGBuilding Irtispe 6/86 and-v1 Z.Net� Q "� _Jritun o� �uec�n3Lsur[�t BUILDING and ZONING DEPARTMENT Bay and Maviland Road, R .D. 1 Box 98 Oueensbury, New York 12801 SEPTIC DISPOSAL SYSTEM INSP TION LOCATION �]� DATE PEF*4IT NCI . 2— y= SOIL TYPE - Sand - Loam - Clay Percolation Test Required? Y N s Percolation rate - Min/Inc FCOS v/ 3 f r TYPE of SYSTEM.: � 4T f / Absorption field , total length Length of each trench Depth of trenches� Size of gravel SEEPAGE PITS4Number of) _ Size- ft . X _ f t_ Gravel size PIPING : Size TY e Bldg . to tank Tank to list . box --- Dist. box to fiel Openings sealed'? YE p artial LOCATION/SEPARATI S : Foundation to tank �t- Foundation to abso n ft • Absorption to lot 1 ' ft. Separation of Pits fG IOCATION VS ON OPERTY (circle one) Front ear - L t sid - Right side - CCMMEN SYSTEM USE APPROV YES i ding inspector 01/86 and vl i own of Queens " rey BUILDING and ZONING DEPARTMENT Bay and Haviland Road, R. D. 1 Box 98 Oueensbury, New York 12801 SEPTIC DISPOSAL SYSTEM INSPECTION NAME LOCAT II ON DATE (�' / PE F2M I T N(] . SOIL TYPE - Sand - Loam Percolation Test Required? YES - NC►* Percolation rate - Min/Inch - TYPE of SYSTEM: Absorption field , total length ' r Length of each trench i Depth of trenches Size of gravel_ SEEPAGE PITS4Nurnber of) Size- ft. X _ ft_ Gravel size PIPING : Size T peG Bldg . to tarok lr Tank to list . box !' !/ List . box to fie / ` Openings sealed? S No Partial LOCATION/SEPARATI Foundation to tan ft. Foundation to alas rpt n ft . Absorption to la line ft. ti Separation of p ' s ft. a� LOC,ATI SYS ON PRO (circle one ) Front - Rear - ft side - ght side - CCAMME SYSTEM USE APPROVED YES NO Bu ' nspector 01/86 and vl ��i �lc+uvn v� �eteert .3h+tere� BUILDING and ZONING DEPARTMENT Bay and Haviiand Road, R.D_ i Box 98 () Oueensbury, New York 12801 BUILDI `NG INSPECTOR ' S REPORT NAME Z I,, . ►'iV� Q tics-sr— LOCATION , T '. 5rZgcW r..Z 1.,�-._ Date tg�/ �—�� Permit Nov LZ - ! 7/ 00' = APPROVED - YE NO Footing/Pier Forms lFoundati.on Waterproofing Backfill Framing Roofing Siding Masonry Veneer Rough Plumbing Relief Valves doom Ext . Porches Finished Floors Interior Trim Stairs & Railings Cellar Drain Tile Concrete Floors Plbg . Fixtures Gar _ Fireproofing Door Closers Smoke Detectors Chimney INSULATION Foundation Floors Walls Ceiling FINAL ELECTRICAL INSPECTION DRIVEWAY APPROVAL Final Building Survey Next scheduled inspection (call when9ready ) Remarks- BuildingInspector +6/86 and-vl �Xp,t o RM 7.. of Quee►rjhury 1r BUfLDING and ZONING DEPARTMENT Bay and Haviland Road, R.D. 1 Box 88 dueensbury, New York 12801 BUILDING INSPECTOR ' S REPORT NAME W ,aVF LOCATION Date, Permit No . ] - ✓ = APPROVED - YE NO )(Footing/Pier Forms Foundation Waterproofing Backfill Framing Roofing Siding Masonry Veneer. Rough Plumbing Relief Valves Ext . Porches Finished Floors Interior Trim _ Stairs & Railings Cellar Drain Tile Concrete Floors Plbq . Fixtures Gar . Fireproofing Door Closers Smoke Detectors Chimney INSULATION : Foundation Floors Walls Ceiling FINAL ELECTRICAL INSPECTION DRIVEWAY APPROVAL FI [ial Building Survey Next scheduled inspection (call when ready ) Remarks- 0 Suildi g Inspector 6/86 and-vl FORM 46-EL, NEW YORK BOARD OF BUILDING DEPT. COPY LLE APPLICATION TH S COPY WITH BUILD NG DEPT. WHEN REQUIRED.FIRE llNDERWRfTERS_ 76110P. fI DATE CITY OR �/'"' TOWNSHIP COUNTY i .r'�•^"i"•+,r" a� !",N VILLAGE STREET AND NO. OR lop POLE NO- ROAD ANO POLE NO. BLOCK LOT BUILDING PREMISE OCATED? '� i ..] J fir: _ OCCUPANT'S i OCCUPANCY NAME 3 �•� h- " / NAE ...'' OWNER'S NAME '4 TEL. AND ADDRESS - CI:IifffEFiT , __. SUPPLIED / '%,� .'� ,i; „ ; FROM THEIR �`s- JA_, OFFICE BU '� DEFECTS BUILDING WORK IS X�NEW OLD ❑ IS NEW • f ADOYTIONAL ❑ REMOVED ❑ LIST BELOW ALL EQUIPMENT WHICH YOU INSTALLED BRAN Na Of Fi:'brn a MOTORS HEATERS CIRCUIITTS OFFICE USE NUMBER OF OUTLETS Leap Raaplaslas ONLY Leda H P. {e11R'e A� W.G- INSPECTION lion CeNkm �j Reap.,. S+ri'Ydl Pe.d.nt Saadcet Nw TYPe Each Na- Each e, Gaa.t side Satlr bass some- event let Ff. Znd FI. 3rd fl. DO NOT USE TH IS SPACE. REMARKS: LIST OTHER ELECTRICAL DEVICES NOT SET FORTH ABOVE: This aPPi ication if intended tc Curer 1110 abu listed egwiPm"% to be lnspmted boI if at time of inspection them is found additional equ iPm t r 11 ahowe listed, wpu are audreriaW to make lfM inepeCtp on and adjust tfia fee to cower the additionai egmpment. m Prowidad bV 111a aPPYicant. 1. ELECTRIC SIGN TOTAL MAINS S LAMPS WATTS MAINS FEEDERS EDf RS CHARACTER EXPOSED GAS TUBE SIGN VA OF WORK CONCEALED TRANSFORMERS OF )CAPACITY) (NUMBER) WORK TO BE COMPLETED SIZE OF SIGH STARTED SERVICE ICE OVERHEAD UNDERGROUND MAKER OF SIGN ENTERS INSPECTION REQUESTED OR AS NF Aft MEW © OLD POMI BL E AVOID DELAY BY GIVING FULL AND ACCURATE iN FORMATION. ALL SPACES DATE OF MUST BE FILLED IN OR APPLICATION MAY BE RETURNED. APPUCATI ON PRINT NAME AND ADDRESS _._, SIGNATURE NAMEOF APPLIGANF 'r�`ff f r f rf � �` I " OF APPLICANT ,� „ � �+ j� ,r` TEL//EPHONE STREET ADDRESS f f FFii) LICENSE NO. CITY OR 4 sa, k ©0DE r" WHEN APPLICABLE POST OFFICE ' 46 EL [REV. If861 A SEPARATE APPLICATION MUST BE FILED FOR EACH SEPARATE BUILDING ire ap� � .' Lor4031 r 1 �'� ✓� He v too o • ti 1 1 1 i d !5 Tq�u"tF F+� +►»" w tt i To 5` 37C l[` �Z.S +�+ „a+r►rTuw-+ e lw r f 1 I 2 s¢ r � w e.fp 35 4f I I 4� ' � � � f h � to t• Za ya1 � \t,, t�c.ax f "1 � ita ' �► � . � ° 3S .�' f 78SLZ08 1 1,08 t3 lee 4414,43 `. 0 �n o w w ly ST+.IE�Its� � ICE tw Mlp N34434, IL { w N � 200 190''ti' / SS' GA►Yto�t M W 3 80 94' "fit cNA �t CA ISLES P + � . `� N