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8055 '{-1 �CERTIFICA.TE OF OCCUPANCY E TOWN OF +QUEENSSURY WARREN COUNTY, NEW YORK 11-cbru� 2.3 SDI 19 t ' r DAte This is to certify that work requested to be done as shown by Permit No, has been completed. b'�.,n t } l 4 �C +�{Y, v P n 11 .,LLL333 3 +r This structure may by, ace,_,.ft9mv MQ YW L,ocarion C k p [37C S Owner "I'• 7"1.m i,+ "} (' T. r } I�il !J�'� �� rL 1 .�f'S 3 By Order Town Board TowN oF QUEENS13URY r i gilding Fr Zoning I pector CRE RYIVE "IM5T.4 P'NINTING GL£n+6 FA L* N Y 12801 "00793-5+90 +CERTIFICATE OF OCCUPANCY TOWN OF QU'EENSSURY WARREN COUNTY, NEW YORK Hate 17 19 This is to certify that work requested to be done as shown by Permit No, has been CAOMPle . � i a Q rn,\ lJ 7�.1►L� tin --- nr? c• -F' ��,� ily This structure may be 0 5pim z � l � lL� �� t• �Y T�r� "' ".a Location Owner OrderBY rder Town Board CT T�^ TT' TC'i'" T r'lv' TOWN OF QIJEENSSURY r '• Building & ZOO Inspector C Riw TVC "�MS'ra" •RIMY�NG. GLEnS IPLLa M w x¢ao � H , alva Deb Rsa . . . �. BUILDING PERMIT t TOWN OF QUEENSBURY No. 8055 WARREN COUNTY, NEW YORK PERMISSION is hereby granted to Patrick and Dolores Lam (Court Douse Estates ) OWNER of property located at Lot 79 MC Cormack Drive Street, Road or Ave_ �l St . # 32 g' in the Town of Queensbury, To Construct or place a one-FaIt_lily I7w+::llincf _ at the above location in accordance to application together with plot plans and other information hereto filed and a approved and in compliance with the Town of Queensbury Building and Zoning Ordinance. t . OWNER'S Address is f�+ 9 Heinrick Circle Glens Falls , New York Q r O rt 2. CONTRACTOR or BUILDER 'S Name {q to Howland Construction Inc . ti a CONTRACTOR at BUILbER 'S Address Box 2251 Glens Falls , New York 4. ARCHITECT'S Name L~ �.l 6. ARCHITECT'S Address tC7 0 t"} Q 6. TYPE of Construction — (Please indicate by XI !}T Wood Frame ; ) Masonry ; I Steel ; y P C7 7. PLANS and Specifications I 64 ' x52 ' 611 per plot plan , specifications and I� No. ,application submitted including two-car attached fD garage and sewage system * 8. Proposed Use One-Family Dwelling c m $ 5 . 00 C/O Paid 1 $ 164 . 00 PERMIT FEE PAID — THIS PERMIT EXPIRES March 1 18 84 (If a longer period is required an application for an extension must be made to the Building and Zoning inspector of the , town of O"aensbury before the expiration date.I F+ Dated at the Town of Queensbury this 19t.h Day of .August t9 83 N SIGNED BY �,1 for the Town of Queensbury Building and Zoning tnspe r TOWN OF QUEENSBURY (Space inside black to bt• filEcrl in by WARREN GDLim'f Y. NEW YORK l3ttildiftgr; 3vaTrc�cwcwl >tipplicaliuir NN7u, Application for 1"ckrmis 1%%tsetl 19, BUILDING AND ZONING PERMIT /At6lnq f:xpirict t9 . i'.r ,rhnr;; 1)�,tritS % alert• rbl Work Copies of a PLOT PLAN, Drawn to scale �i'1 rr ' , • ti t'�' THREE ( 3l Cop l showiwg the actual dimensions of the Oat to be built Itt•m,i+ iCf' upon, Tk� exact sir. and location an the W of the building to bsi erected or altered WI H THIS APPLICATIONivIUST BE SUB- M TTED i'O'i+0+N OF [ )IJEITN+L�f'sftg;,..! U Li RUG '�` 1�tsi A PERMIT MUST BE OBTAINED BEFORE BEGINNING WORK ANSWER ALL OF THE FOLLOWING. POW 1 2 3 4 6 6 The undersigned hereby applies for a permit to do the following wblalt $ "' ' ■ • +� ■ ■ � 'i � � which will br done in accordance with the description, plans and p cifi• � ©v yl Clue cations, and such special conditio-�yns as may be indicated on the rmit. 1G PigTYiCK 4 boforeS LQM The tswneFaof,this property is: rr / _ ffr37��r'.�. tI^ ' 1.,•�•',+�',�' G'f lT"T " +� . 7`'r fi . .e''sm..sxc.,�E` G�7*.E'.�' , 4?sa: i{+"�,. . ./.E+ .'`.! tNA AE] fP.O.0 f� . AgOES51 The person responsible for supervision of the work insofar as the buildi;*.C.cicie and the Zoning Ordinance apply is: . /.]'F"te.1,4/.�r'9'.lt.'r';^e! C 1',�.':-+;?'�Y 4;f iG.^;�. .... .-�c: f ..6!-J,K•,'%' o• .f p 14 5S C'L�S . {HAA4f1 / Name of Builder . . - . . Srf?a? t , .? Ei •�c . . . . . . . . . . . . . . . . Address . . . . . . . . . . . - - . . - . . . . . . . , . . . . . . - . - . . . . - . . . Name of Plumber . . . +fCoe . . . . . . . . . . . . . . . . . Address �.p �'� ?7Ges. f ' : . , . . . . . , . . .e G? � [ . . . . . . . . . . . . . . . - - . . . . Address . . . . Name of Mason . �. . . . . . . . . , . `l. . . Unit . . . . . . . . . . . . Estimated value of proposed works �!4 �" '�% . . . . . . . . . . . . . . . . Lot Number . Name of village • . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . . . . , . - . : . ;: : , Name of Street . . - - Side of.lstreev north SY, east . ❑. souith ❑ . west ❑ t Nearest Cross Stree 1c r llsli [xo� Lin. r.�,. . . - . . . . . , - . Distance from, this �ross street . . . . . , , . - . , , 1 , - Ft. Property is north ❑ , south ❑ , east i i , west from - ross Street . If (m Corner, which corner. northeast O v northwest ❑ , southeast southwe%t (Designate by marking with an "X" in the. correct space.1 MATURE OF PROPOSED WORK OCCUPANCY Main Hlslitling Construction of a new building. One-ramily dwelling Addition to a building. Two-familv dwelling 0 0 Alteration to a building. , , , , . -family apartment house � C] Demolition of a building. Store building a a -car attached garage M, Accessory Building 0 One-car detached ,garage © Other work, Describe: . . . . . . . . . . . . . . . . . . . . . . Two-car detached garage � Private chicken house . . . . . . . . • , . - . . . . . . Private storage building ZONING SPECIFICATIONS. Fill in for new building, or addition to existing building, or a change of occupanCY- Indicate on the plot plan street namest the location and size of the property, the location. size and setbacks of pro- posed buildings, and the location of all existing buildings. luowrlu Show proposed building(s) in dotted line and existing lfuilding(s) in solid line. Sire of property . . . . . . I. r. . . ft. at . . . �' . . it, - ., Sire and use of existing buildings. if any - Q . . . . . . . . . . . . . . . . . . . . . . . 4' y . . . " Sire of proposed building . , . ft. Height (from grade to rid") , . ��'" ft. `k7 y t'tU Front yard . . . . . .. . .C- :i ; . . , . . . . . . . . . . . . , . . . . . . . - ft, r 3 e7 ft. and ht/ . . . . . . . ft, Side yards Rear yard . r• • • • ft. ,/�%C LG'e�rYl/1 t .t G1/'r•G't` . . . . • . . . . , . ft. SOUTH if op corner, setback from side street . , . - . . . . . . Note: All distances are net, as measured front street side line to nearest part of building. (Oven) 7-73—M (ront'd.) BUILDING SPECIFICATIONS., Kind of construction : Wood frame, fire safe, etc.? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Will any second-hand lumber be used? . . . . . . . . If so, for what?. . » » . . . . . . . . . . . . . . . . . . . Material of foundation walls . . . . . . . Cs4^. - . Thickness „r. i Depth of foundation walls below grade . . . . . ? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Continuous foundation? Will there be a cellar? cf,r. . . . . . . . . . If so, material of cellar floor . . tom. c c' �' ? r , 5c .57 r3 Type of roof Sloped or fitrt? Material of roof . . . . !r! �!s!-s� . . . ,�c[7� •F, . ?+f�'�r �s . . - Size, wood studs . . . . . . . _ . . . - . . , , , . " x . . . . . !rt. . . . . . . . •`„ spacing . . . . . , /� - . . . . "o.c length . . . . -�. . . , . . - ft.Size, floor beams, 1st floor . . . . . . . . . . tox . . . . . . /C! . . . . . . ", sparing . . , . . !„E. . . . . ."o.c., span . . , . .! � . . . . . . ft. Size, floor beams, 2nd floor . . . ? . . . . . . ^ x . . . . . Z44 . . . . . . . ", spacing , - . . . ✓`C •'o.c., span . . . / s? :r'3. '!E' . . ft.Size, ceiling beams - "„ spacing - . :fir-. . '"�o.c., span • .. ft. Sii"e, roof rafters or beams . . . . . . . , spacing . . . . . . . . . . . " p . • . . . . . . . ..K.-!r'��'1 . . , . " x , , , . - . _ " - o.c., span . . . . . . . . . . . . . . ft. Exterior Finish . . . _ _ -Ale , r�. <3 . . . . . . . . , . . . . With what material? . 4 '<?•?•o' V *!,ecI.5.o're -z �, , ,1 s,,. Finish of interior walls . . . . . . . '. . . !?� '!??� . . - 7�1`e ^.4G?do� t . . . . . . . . . . . . . . . . . . . . . . , . . . . If garage is to be attached, of what material is wall between garare and main buil ing to be constructed? Is there to be an opening between garage and building? . . VA4 5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Kind of heating system . . . . . oVZ+t4 •'r.4w . . . . . . . . . . . . . . . . . . . . Oil burner or coal? . . . . . . . . . . . . . . . . . . . . . - . . . . . . . Will a flue-lined chimney be provided? . eV 0 . . . . . . . . . . Depth of chititttey foundation below grade . —. . . . . . Height of chimney above roof . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Will there be a fireplace? . . . rdA.OeJo . . . . . . . . . . . . . Depth of fireplace hearth . . . /g�: . . . . . . . . . . . . . . . . Will a toilet be installed? . Y40t,.4�j . . . . . . . . . . . . . . . . '. . . . . . . _ . . . . . . . . . . . - . . . . . . . . , . . Will a kitchen sink be installed and connected to water supply? . .at .? - . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Water supply (public water supply or pump) I u46t. . . . . . . . . . . . . . . Distance of cesspool from any private well . . . . !t `, ? : . . . . . . . . . . . . . Will drainage system be provided with required traps, a A feet l'+ y P e9 l�� cleanouts, and vents. ,s. . 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Town of Queenshury AMDAYIT County of Warren State of New York I swear that to tit. ova i of my knowledge and belief the gatatnarsis contained in this appiicetkmi together with The plans end apseiii*eatiaea sub- mitted, are a true and m.a. lete statement of all proposed work to be done on the desaGibad premises and the t aA cR the BLIIIob ING CODE, THE ZONING ORDINANCE, and all other laws pertaining to posed be complied with. vulNwaes spec Tied w no , and that such work is authorised by the owner. / Sworn to before me this sign,aturo . . . . . . /,._. C' `s as ,.z:F /r owNe". oVN/NER's AGEN�gCMITEC CONTRACTidR dayof. . . .. . . . . .. .. .. .. . . . .. . .... .. . .... . ... . ..19. . .... ., NOTARY PUBLIC. WARREN COUNTY, N. Y- SPECIAL CONDITIONS OF TIME PERMIT: my .. .. . 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 // -S 2 . Type of heat clrfc 3 . Is the building mechanically cooled ? W6 . 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 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 floor ? 4 . Is basement heated ? YES NO a . R value of insulation 5 . Type of insulation B . Under 16 % only 1 . R value of roof and floors exposed to ambient conditions _ R �3 f5 'e c- e:) 6 -- JE f�j 2 . R value of exterior walls 3 . R value of glazed area R c' 4 . R value of doors P, 1 }` 5 . R value of floors over unheated spaces R f q 6 . R value of slab edge insulation - unheated slab JO 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 flBk�.@r / r1SS c . Controls / 1 . Thermostat maximum heat settingT 15Z2 Z2 +40r9PQ1) 3540 7,5- `� D3 Duct Systems 1 . Is duct system installed in unheated spaces ? YES a . If YES , R value of duct installation 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 F . Service Water Heating 1 . Performance efficiency 2 . Temperature control setting maximum G . For Swimming Pool only 1 . Maximum heating Telephone No . `7573 -e^ o - ( ap licant ' s signature ) TOWN OF QUE'ENSBURY BUILDING & ZONING DEPARTMENT SEWAGE DISPOSAL PERMIT APPLICATION 1 . Owner ' s Name_ � Tr'�G ^i9 •r ,-� Address Telephone No . 2 . Property location 4 :7c/ C c o +� fdr�^( s.r s774 `cif 5 3 . Name of/person or /firm responsible for installing system Telephone No . . i� Address 2 U_ ec, ,x 225 / r'!5 �00• 0 4 . Number of bedrooms ( residential buildings only) 5 . Daily flaw gallons/day 6 . Septic tank capacity A/ )e9G) gallons 7 . Topography : flat rolling , steep % of slope 8 . Nature of soil and depth 9 . If ground water , bedrock or impervious material is apparent at what depth does it begin? 101`.4 ft . 10 . Percolation test - A is required B is not required C--If required what is the rate / minutes/inch 11 . Water supply : municipal , well , other ,,� '..J5-4/0,en ez J,A r 12 . Type of system proposed : drywell , ti_le field , 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 Queensburrly Sanitary Sewage Ordinance . Date T s gnature of app lccnt On separate sheet of paper submit a diagram of the proposed 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 TOWN OF QUEENSSURY Suildins Department inspacbms ROP*wt Date a x , / Nwase �A Perm Noy ��_'" W'eatlser, Remarks Excaj�atson Footing Farms Footing & Piers Foundation Cement Coat Water raofin ,Bgckfill F.fnal Surve Fra do sheer thi n Roof Fe1 t Roafin Siding M,asonru veneer Rau h P1 Relief valves Wall Board .[sxt . Parches Finished Floor lrnterior s'rim Stairs & Rail.in s Cellar Dr , Tile Concrete Floors gl Fixtures Gar . Fire roofin Door Closers Chimne water Meter Inst . Se tic A raval Floors Foundation insulation W4a 3i Building I spector REMARK'S cam � � sS _ 4000384 THE NEW YORK BOARD OF FIRE UNDERWRITERS BUREAU OF ELECTRICITY 41 STATE STREET, ALBANY, NEW YORK 12207 February 2 , 1984 Application No. on fate 037997-83 A 615846 1141S CERTIFIES THAT way the electrical equipment as described below and hatrothwed by the applicwnt named an the above application number in the premises of Howland Const . Co . , inc . , McCormack Drive , Quee#nsbury , New York 79 _ in the feliawing location; M Basement � 7at Ff. � Zmd Fl. garage OTlt S idiE Section Block Lot was examined on I and found to be in compliance with, the requirements of this Board. 1 /30 pXTURE IRITACIlS SWITCHES LE RXTURES RANGES COOKING DECKS OVENS DISH WASHERS EXHAUST FANS CMITTS INCA►IOESCEPIi FWOAESCEHT I AMT. K. W. AMT. K. W. MAT. K.W. AMT. K. W. AMT. H. P. 35 49 41 3 Fr . DRYERS FURNACE MOTORS PI APPLIANCE FEEDERS SPECIAL RECPT TIME CLOCKS BELL UNIT HEATERS IMtlL71-GIITtEt DiMINERS AMT. K. W. CKl H. P. GAS H. P. T. P40. . Si. AMT. AMP. AMT. AMPS. TRANS. AMi. H. P. SYSTEMS .AMT.' WATTS _.. }�t�,rTf �y 'I NO.Of FEET y„ 1 LdILZ6� -w H 1 10 y SERVICE DISCONNECT MW S E R '� Ga V 1 C E AMT. AMP. TYPE EOIMP. 1 ,r 'iW 1 X 3W S Ar 3W S X 4W �� �iPEK OF OC. G IMP. NP. QP H41lG CO •�'� NO. OF HEU'fewl, OF NWEl1 RAl _ l 200 CB 1 x 4 /0 . /f' OTHER APPARATUS: Electric Room. Heaters : 3- 2 . 0 kw, 4- 1 . 5 kw, 3- 1 . 0 kw , 2- . 75 kw , 1 - . 5 trw 1 - Smoke detector 2 - 15 amp GFI Breakers William C . Carpenter Assoc . , Inc . . . 0 . Box 2014 239 Glens Falls , New York 1. 2801 BRANCH MANAGER per ' r ; J COPY FOR BUILDING DEPARTMENT. THIS COPY OF CERTIFICATE MUST NOT BE ALTERED IN ANY (MANNER. � eA g LI1LOINLi pEPT- COP FF L RE LI TJDERWRITERS. COPY WITH BUYLD(Nd DE PT. WHEN REQUIRED, FILE THIS X. CITY OR TOWNSHIP { „LJ COUNTY LLAGE REET AND NO. OR ,iM/' r �I''„ POLE NO- ROAD AND POLE NO. ! BETWEEN WHAT TWO BLOCK LOT CROSS STREETS IS SECTION PREMISES LOCAT£'D7� BUILDING OCCUPANT'S OCCUPANCY ('„t,.J NAME OWNER'S NAME �i v , AND ADDRESS i SUPPLIED FROM THEIR OFFICE SY WORK DEFECTS BUILDING IS NEW ADDITIONAL © REMOVED ❑ IS NEW OLD ❑ REMODELED ❑ LIST BELOW ALL EQUIPMENT WHICH YOU INSTALLED No. of Fixtures & HEATERS BRANCH LAMPS NUMBER OF OUTLETS Lamp Recepsaclas MOTORS CIRCUIT'S Lorca- A.W.G- WATTS tion Side Attach't H. c Watts No. NO. EACH Ceiling Wall Recapt'Is Switch Pendent Bracket No. Typo Each No. Each Gauge Out- Side Sub_ bass Base- e) Mont / 1stFI. 2nd Fl. 3rd FI- _ DO NOT USE THIS SPACE. REMARKS: LIST OTHER ELECTRICAL DEVICES NUT SET F IJInl" ABOVE' f - on lfbrra is found additional equiPment not abore listed. This a Ication is in to yeller the abore.listed equipment to be inspected but if et time of inspection you an authorised to make the inspection and adjust the fee to cover thr additional eLE RInC�+ as provided by the applicant .TOTAL SIZE OF �.� !.7 LAMPS WATTS MAINS FEEDERS CHARACTER W POSED GASS CO D T RANSF ORM E RS OF VA OF ORK f N UMBER 1 1C APAC I TY 1 WDRK TO BE COMPLETED SIZE OF SIGN STARTED MAKER SERVICE - OF SIGN ENTERS ..j, ` ,;:..cs ,+,, ✓ 1 1 INSPECTION REQUESTED NEYY OLD El ON OR AS NEAR AS POSSIBLE AVOID DELAY BY GIVING FULL AND ACCURATE. IN FOr RM/AT IION. ALL SPACES MUST BCE.,-[yF,-f1,�/4LED IN 4R APPLICATI N MAY BED ETURNED- / A -f4. / J J tr ./ ; 1� ." , 'GATE OFJ` NAME DF rjH f -I C�. 1 7�C�- I —� APPLICATION APPLICANT �' � � .� STREET ADDRESS, r ZIP `� �/" WHEN APPL_.A.LE CITY OR :' [.'��✓� � ' POST OFFICE A SEPARATE APPLICATION MIDST BE FILED FOR EACH SEPARATE BUILDING r TOWN OF Q►UEENSBURY Building Department h2spodk rs Report Name LAMMMOM Peennet ,N��' s��;� � W�►ther Remarxs Exca%pa t!on Footln2 Foz7ns Footing & Piers Foundation Cement Coat rater roofin Bac&fill Final Survey Fxamlng sheathing Roof Felt Roofing Siding Masc+nr Veneer Rough PI Relief Valves wall Board Ext . Porches 4 Finished Floor Interior Trim Stairs & Raili s Cellar Dr . Tile Concrete Floors Plbg . Fixtures Gar . Fire roofi.n Door Closers Chimney Water Meter InSt . Se tic Approval Floors Foundation Insulation Walls -- Cei I in ui ding spector ,REMARKS 5wM d kE ,)ETr=Z 7V)C5 - C Y TOWN OF CUEENSBURY Building Department inapacbw* OF M Dates'- Name pamgt Na Weatbw Remarks ,�xcatYa tson Footing Forms Foots & Piers Foundation Cement Coat Water roorin Bac.?cfil.I Final Surwe Framin ' Sheathing Roof Fel It Roofin Siding ltasonr veneer Rough P. r Relief valves Wall Board sxt . Porches Finished Floor rnterior Trim Stairs & Rai- s Cellar DrII, Tile Concrete Floors Pl , Fixtares Gar . Fsre roofin Door Closers 11 Chimney •- Water Meter rnst . Septic ApPrOvaj Floors rnsulation Foundation Walls ceiling Building rnsppector / REMARKS b!1. `"> or TOWN OF QUEENSBURY Building- Department b"Pec6 a Rwqpwt Date___ Name P Nay. s' a �- Weather— Remarks y ExcatYa ti an Footing Farms Footing & Hers Foundation Cement Coat Waterproofing 2,�saJicfill ' Final Survey Fr min Sheathin Roof Pal t RoofIn Sidin Masonry veneer Rough P1 Relief Valves Wall Boaxd Ext . Parches Pl rLLshed Floor Interior Trim stairs & Railings Cellar Dr . Tile Concrete Floors Pl Fixtures Car . Fire raofin Door Closers Chimney water Meter Inst , Septic ApEroval F20OZ-5 Insulation Foundation Walls Ceili Building Inspector REMARKS TOWN OF QUEENSBURY Buiihupoebwe ldianr aepartmeat N Resort nay ' , " t.acw ParPIN +mit Na 'W'ratheir - - T s.. _ Rc-!rqa rlrs Excatra ti on PI ng Forms Footing & Piers Founda tJ on Cement Coat Water roofzn Bachfill Final survey Framin Shea thi n Roof Felt Roofin Siding 1Mlasonr Veneer Rau h P1 Relief Valves Wall Board Ext . Porches Finished Floor Interior Trim stairs & Raili.n s Cellar Dr . Tile Concrete Floors Pl . Fixtures Gar . Fire roofin ` Door Closers Chimne Water Meter Snst . Septic Approval Floors Insulation Poundation Wall s Ceiling Building Building .inspector REMARKS BUILDING DEPT. COPY OF APPLICATION FORM 46-EL, NEW YORK BOARD OF FIRE UNIDERVwniTERS. CITY DR FILE THIS COPY WITH BUILDING DEPT, WHEN REQUIRED_ }� VILLAGE TOWNSHIP r J STREET AND NO. OR COUNTY i ROAD ANO POLE NO. f l..-* BETWEEN WHAT TMYp POLE NO. CROSS STREETS IS PREMI ES L ATE07 SECTION OCCUPANT'S ;. BLOCK LOT NAME r r BUILDING OCCUPANCY OWNER"5 NAME AND ADDRESS + BSUPPLIED 3: FROM THEIR . ' r BUILDING WO R K OFFICE IS NEW OLD EN] REMODELED ❑ DEFECTS IS NEW ADDITIONAL © REMOVED ❑ LIST BELOW ALL EQUIPMENT WHICH YOU INSTALLED NUMBER OF OUTLETS No. of Fixtoraa A BRANCH Lecr Lamp Rearpfaclaa MOTORS HEATERS CIRCUITS NUMBER OF LAMPS tim Side Attach"t Switch H.P. Watts(AiF1 Wall Racap'h pa BracRet No. Type A W.O. Each IH o. Each No. Gauge I F M.V. Ouv $ilo b" Saar mr.x 1st Fl. 2nd Fl. 8rd Fl. ST HER ELEC IC DEVICES NOT ET FORTH ABOVE: DO NOT USE THIS SPACE. Thia application is intended to Cover the above-nztad equiprMMt to be inapacted but " at time of i YOU are authorized to make the inapaeti on and adjuat the fee to cover the additional +Intention there Is found additional equipmrnt not abevr Iistad, aquipmerM as Pr ' Ind by the applicant. 312E OF MAINS FEEDERS ELECTR IC INS TOTAL CHARACTER LAMINWATTS OF WORK EXPOSED GAS TUBE SIGN CONCEALED TRANSFORMERS OF VA WORK TO BE STARTED COMPLETED iNUMBE5 (CAPACITY) SERVICE SIZE OF SIGN ETERS MAK N ER I INSPECTION REQUESTED OF SIGN PO SI LE NEAR AS �-t POSSIBLE NEW 1_I OLDEJ AVOID DELAY BY GIVING FULL AND ACCURATE INFORMATION, ALL SPACES MUST BE FILLED IN OR APPLICATION MAY BE RETURNED. PRINT NAME AND ADDRESS NAME OF APPLICANT ?,a .� pr' / � - . DATE OF APPLfCATION / '�' STR E ET ADOR ESS CITY OR r- POST OFFICE :"r-a .fr .+ • / ^ .r,%. CODE IP . zr e LICENSE SE LCABiE +a EL (REV. 1/") A SEPARATE APPLICATION MUST BE FILED FOR EACH SEPARATE BUILDING ZG , + i + I » ` + ti. r s , , • e , , _ L> • m •