1987-298 G
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CERTIFICATE OF OCCUPANCY
TOWN OF +QUEENSBURY
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WARREN COUNTY, NEW YORK �
5 � 13
A at 5 , 19 87
DateThis is to certify that work requested to be done as shown by Permit No. 87-298
has been completed. �..+�� �`f�►�11 ���� l
This structure may be occupiS4 as a fine Family elling
tck V rVTGORk viz(x
LA3Cati0n Lot Phe sa t Walk (St. No . 19 Sectlon II Pheasant Walk Sala .
Owner Pro--Graf t , nt (y)
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By Order Town Board
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"TOWN OF QUEENSBURY
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Building & Zoning Inspector
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BUILDING PERMIT
TOWN OF QUEENSBURY No. 87-298 +
WARREN COUNTY, NEW YORRK
PERMISSION is hereby granted to Pro-Craft , Inc . *d
0
0
OWNER of property located at
Lot e 35 Pheasant Walk (St . No . 19 ) Street, Road or Ave. l
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in the Town of Queensbury, To Construct or place a One-Family Dwellingram*
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.
F2CONTRACTOR
WNER'S Address is 11 Pheasant Walk
Queensbury , NY
or BUl LDE R'S Name Same
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3, CONTRACTOR or BUILDERS Address r5y
same
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4. ARCHITECTS Name Ca �
to �
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5. ARCHITECT"= Address r-r
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ex' o
6. TYPE of Construction — (Please indicate by X) ~
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(X ) wood Frame f ) Masonry I ) Steel ( )
7. PLANS and Specifications p
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No.
60 ' x34r per plot plan , specifications and application m
including sewage system and two-car attached. garage .�
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8» Proposed Use F-
One-Family Dwelling
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$5 . 00 C /O ~
December 1 87 T
108 . 00 '
PERMIT FEE PAID - THIS PERMIT EXPIRES 19 ara
(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 29th Day of May 19 87
SIGNED BY __ ` for the Town of Queensbury
Building and Zoning Inspector
TO BE COMPLETED BY BLDG . DEPT .
�r / Application NO .
_town o/ 4 venji "Pq Permit IssuedIII 19 I TO WN OF' QUe.INSBI ;?Y
BUILDING and ZONING DEPARTMENT Permit Expires 19 i
Bay and Haviland Road, R.D. I Box 98 Zoning Designation
Queensbury, New York 12801 variance No . I
Site Plan view No MAY 2 71987
�] Approv b BUILDINGGj�&GCODE DEPT.
APPLICATION FOR 1 113 '- I
BUILDING AND ZONING 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 .
The owner of this property is :, ,�'
P . O. Address s ZED e'"L Tel
Property Location : � C7 / ._ - / ' y Tax Map No . f /
Street number or building lot number
Subdivision name ( if applicable) ! / - `�S ,�I/ � �'49-/
THE PERSON RESPONSIBLE FOR SUPERVISION of WORK AS REGARDS BUILDING CODES IS :
�'/7/✓K �-Kc _ 6�Lc S tEl3cLS V79 .0 / 33
Name P . O. Address Tel . No .
Name of builder ///eCJ _Address L'r � Tel . ,7 aF 33
Name of plumber G , •� Address Tel ' 7-J ; 3 3
Name of mason /�) 5 Address Tel . 7Q2 � !
NATURE OF PROPOSED WORK : ZONING INFORMATION :
1X' 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
street and number or lot number and indicate
whether interior or corner Iota Show location.
FOR DEMOLITION PERMIT , STATE SIZE AND * of water supply and location and configuration
LOCATION OF STRUCTURES AFFECTED* of septic disposal area .
* COMPLETE INFORMATION REQUIRED BELOW .
Size of property / "/ }(' .2731?C ! 3`L` XX
Existing buildings) Size ft X ft -
x
PROPOSED BUILDING AND USE : Existing building ( s ) Use
Size of new structure .._-6-.ft
Foundation-pier/slab/crawl/parties ul Proposed building , distance from property line
(circle one )
Front yard Is-6 ft Rear yard fS ft
No . of stories (habitable space ) , .' Side yards 2"5 ft and 2 3 ft
Height (grade to ridge) / r� ft . If on corner , setback from side street ft
It residential , no . of fame es /
No . of rooms ( excluding baths ) OCCUPANCY INFORMATION
Now of bedrooms 3 PRIMARY BUILDING
Na . of bathrooms „/ * V'One family dwelling
Primary heating system * Two family dwelling
Type of fuel e G&j G * Multiple dwelling / dumber of units
No . of fireplaces to be installed /+ O �/ Permanent occupancy
will a wood stove be installed? LL.7d7 Transient occupancy
Central Air conditioning? ^ / U
W Business
BUILDING STYLE, PRIMARY STRUCTURE Industrial
* Other
Rant Contemporary Log cabin If addition , what will use be?
Raised ranch Mansion Duplex
Split level Old style Bungalow
Cape Cod Cottage other ACCESSORY BUILDING-
Colonial Row Town House Detached garage/one car/ two car/ car
( CIRCLE ONE PLEASE ) Attached garage/one car/ C_��-==' ' car
Private storage building
ESTIMATED MARKET VALUE OF * Other
CONSTRUCTION
- - - - -
INFORMATION ON BUILDING SPECIFICATIONS , ON REVERSE SIDE OF THIS SHEET , To BE COMPLETED !
Form BPA 4/86 and-vl
BUILDING PERMIT APPLICATION CONTINUED
BUILDING SPECIFICATIONS :
Type of construction od fra , fire safe , etc .
Will any second-hand or ungraded lumber be used? If so , for what ? A'I-e
Foundation wall material Aoz- e_ d_ ,/w Thickness 140
Depth of foundation below grade (to bottom of footing )
Will there be a cellar?�Lk �Heated or unheated? v.,� r Floor sq. footage���G �sq ft Will there be a basement? Y S • Will any portion be used as living space?- ,yam
( If so , what port � _sgoft . - - Type of use?
Type of roof - oPe flat/shed/other Material of roof ��-
Size , wood. studs 2"X � spaeing_.�"o . c _ length _ �' ft .
Jaists ( floor beams ) 1st . floor 2 "X /a spacing���"o . a . span_ �ft .
Joists ( floor beams ) 2nd . floor ---- "?�i- "' spacing "o . c . span ft .
Overlays (ceiling beams ) - spacing '"o . co span ft .
Roof rafters --J" *spacing o . c . span ft ,
Roof trusses (,pre-engineered) spacing_ + "o . c _ span c2 .3 ft .
Exterior wall finish G mac , Of what material ? VIAOV l
Interior wall finish �7,*OKAA �
If a�•�garage is to be attached , describe materials to be used. for FIRE SEPARATION :
Is there to be an opening between garage +and dwelling? TYE 5 If so will a Fire-rated
door , enclosure , and self-closing device be provided? Yc S
Will a flue-lined chimney be installed? Alec) Height above roof ft .
Depth of chimney foundation below grade ft .
Depth of fireplace hearth t , in ,
Water supply unicipa gr private well
SEPTIC SYSTEM � distance from ANY private well ( ,
ncluding adjoining properties ft .
(A separate application is necessary for any repair or new installation of septic system)
Town of e A F F I D A V I T STATE OF NEW YORK
n
County off 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 BEFORE ME THIS signature
--- Owner , Owner ' s agentpa nirei7tf contractor
Notary Public , Warren County , N . Y .
* * * * * * * * * * * * * * * * * * * ,t * * * * * Ar * * *
SPECIAL CONDITIONS OF THE PERMIT :
TOWN OF QUEENSBURY
WARREN COUNTY , NEW 'YORK
Application for : BUILDING
PERMIT IN CONSERCOMPL CODE
COMPLIANCE WITH TIME NEW YORK
STATE
A permit must be obtained before beginning work .
ANSWER ALL of the following :
1 . Gross floor area
2 . Type of heat
3 . Is the building mechanically cooled ? - .Ro/ 01
.p
4 . percentage of area of windows and doors o3 U
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.
lose 3
2 . R value of exterior walls
3 . R value of glazed area /;!'
4 . R value of doors III< 2In
5 . R value of floors over unheated spaces
60 R value of slab edge insulation - unheated slab
7 . R value of slab insulati. on - heated slab
s . R value of heated basement/ cellar walls ( above grade )
9 . R value of heated basement /cellar walls ( below grade )
10 , Type of insulation ZE:2a.�.k' � � /5'S
Co. 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
b . R value of duct in other areas -� -�"-
EI, piping Insulation
1 . Size of hot water or coaling carrying agent pipe
2 . R value of pipe insulation
F . Service Water Heating
1 . Performance efficiency ff p
2 . Temperature control setting maximum
G . For Swimming POO Only
1 . Maximum heating
Telephone No . k 1173
+( applicant ` s signatur )
./ -'� L-''. vc
APPI.ICA77ON FOR SEPTIC DISPOSAL PERMIT
DATE
LOCATION OF PROPERTY FOR INSTALLATION aeo
Owner's Name: Z40 C .^ xyle / /�4 c Telephone:
Address: _ z/ /
Installer's Name: � �C� "^' �,L�J� Telephone: �% �-3
Number of bedrooms (residential only) �3 _
Total daily flow (compute @ 150 gal per bedroom)
Topography: circle one: Flat Rolling Steep Slope 9� of slope _
Soil Nature: circle one** ( Sand Loam Clay Other / Depth: feet
Grouted. Water: At what depth? feet
Bedrock. or Impervious Material: At what depth? � feet
Percolation test: circle one: not required required / rate min. inch.
Domestic water supply: circle one: Municipal Well Other
IF domestic water supply is a Well:
Separation: Watersupply from Septic absorption _ feet
PROPOSED SYSTEM : Septic Tank ILVOO gal. (minimum size: 1 ,000 gal.)
TILE FIELD: Each Trench feet / Total system length � feet
SEEPAGE PIT(S) : Number of "-7 Size each �e'et by ""feet
Size of stone to be used # Depth or Thickness �r feet
IMPORTANT
.__Please...LIST NEW EQUIPMENT TO BE INSTALI.EI�
(over)
Section H 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
Be 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 L)isposal ChxUriance.
Signature of responsible person;
Date: 2 -
Town of Queensbury
Building and Code Department
Bay at Haviland Road
Queensbury, New York 12801
(518) 792-5832
SETTLED 1763 , HOME OF NATURAL BEAUTY A GOOD. PLACE TO LIVE
BOARD OF FIRE UNDERWRITERS
THE NEW YQRK �.
BUREAU OF ELECTRICITY
gYl3 At STATE STREET, ALBANY. NEW YORK 12207
October 30 , 1987 Application No. an file, 01 301 9 /jr7 A 698849
Date
THIS CERTIFIES THAT
only the etectrical equipn ent as described belt rsn and intraahaced bar she applicant nar.aed on the above .ppl.cation rwmber in tics premises al i=
Pro-Craft , lnc . , Lot 35r Pheasant Walk , Q"aensburyr Now York �
in thefa[lonving location. � Sasemenl � Ysl Ff. El $nd Ff. oicculde Section Block Lot
was examined on a/ 14 / 8 7 anal found to be in compliance with the ""irernents of this Board. rl
FIXTURE is
FIXTURES RANiGES COMING DECKS OVENS DISH WASHERS EXHAUST
(XTLRTS RClFTACUTS 5WITt ttES jNCANDESCENT RLK]REs"NT AMT. K- W. AMT- K. W. AMT- K,W- AMr. K. W. AMT. M. I
43 43 18 22 1 1 l . b l Fr
DRYERS FURNACE MOTORS FUTURE AU'FUAH" FEEDERS SNECIAL REC'FT TIME CLOCKS REu IIMtT HEATERS MUL 11 D111EMIER5
AMT_ K. W- OIL H. P- GAS H- r AMT. No. A. W- G. AMT- AMP. AMT. AMPS. TRAMS. AMT. H- I. M1:1. ( ITT AMT, WATT5
SERVICE DISCONNECT MO.OF S E R V I C E
AUTERNa. or cc- CONS. A. W. G. A. W. a. NO. of NEIiTKALS
AMT. AMP. TYPE EQUIP, 1 .e 2W 1 0 3W 3 X 3W 3 .s Aw PEC s' of CC. CONtr. tJC1- t7► HI-EEG of WtEG of FiEUTRAL 7
1 20[ GS i X 4/ 0 2 / 0
S
OTHER A►FARATUS; z
1 GrCl 1 smoke t1tcCar E
electric room heaters 3 2 . 0 KW `
4 1 r 5 tCW Ey �a M «`" �
'4 �' C
2 1 . 0 KW
rr
T Pro Craft Ix1c .
1 i Phea.zant Walk U
Gl1s Ls Falls , New York 12801 BRANCH MANAGER
Per
This certificate most not be altered in any manner; return to the office of the Board if incorrect_ Inspectors may be identified by their credentials.
COPY FOR BUILDING DEPARTMENT. THIS COPY OF CERTIFICATE MUST NOT BE ALTERED IN ANY MANNER,
BUILDING and ZoNmG DEPARTMENT
Say and Haviland Road, R.D . 1 Box 98
pueensbUry. New York 12801
BUILDING INSPECTOR ' 5 REPORT
NAME 4 +Z" r
LOCATION IeFr ✓ �r �3�y t `
permit Nc� . f ``.
[lateIIII
* * * *
A -* YES NO
ppRaVEi7
Footing/Fier Forms
Foundation
waterproofing
B,ackfill
Framing
Roofing
Siding
Masonry Veneer
Rough Plumbing
Relief Valves
Ext . porches
Finished Floors
interior Trim
Stairs & Railing'
Cellar Drain Tile �-
Concrete Floors
plbg . Fixtures
Gar . Fireproofing
Door Closers
Smoke Detectors
Chimney
INSULATION
Foundation
Floors
walls
Ceiling
FINAL ELECT IC AL INSPECTION7��
DRIVEWAY ROVA
final Bui ding Survey
AIF
Next scheduled inspection (call when ,ready )
Remarks-
erl r 4
R ing Inspector
6/86 and-VI
�lo+wn vueen36e� r�
BUILDING and ZONING DEPARTMENT
Bay and Haviland Road, R .O. 1 Box 98
Oueensbury, New York 12801
SEPTIC DISPOSArrL SYSTEM INSPECTION
NAME _ 4'r
LOCATION �J L�}
LATE / / / PERMIT NO. _
SOIL TYPE - .Sand - Loam - Clay
Percolation Test Required? YES - NO
Percolation rate - Min/Inch _
TYPE of SYSTEM:
Absorption field , total length
Length of each trench
Depth of trenches
Size of gravel—
SEEPAGE PITS{Nummber of) _
Size- ft. X
Gravel size —
PIPING : Si Ty
Bldg _ to tank
Tank to list_
Dist_ box to fie /
Openings sealed? YES NO Partial
LOCATION/SEPA ION `
Foundation to ank fto
Foundation t absorpti ft -
Absorption t lot line pr�ft.
separation f pits fto
WCAT STEM ON PROP TY (circle one)
Front Re r - eft side - 4ght side -
CCiMMEN
SYSTEM USE APPROVED YES NO
Build ' g Inspector
01/86 and vl
Mourn 01 Queenshury
13UILDING and ZONING DEPARTMENT
Bay and Haviland Road, R.D. 1 'BOX 98
Oueensbury, New York 12801
BUILDING INSPECTOR ' S REPORT
NAME PrZO
LOCATION L04yr .r + 1��4`'$ I�►rA�' � L�
Date/?.7 Permit No .
APPROVED - YES NO
Footing/Pier Forms
Foundation
waterproofing
Backfill
Framing At5OP
Roofing
Siding
Masonry Veneer
Rough Plumbing
Relief Valves
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 APPROV
Final Building Survey
Next scheduled inspection ( call when ready
Remarks-
pt,ra-camt/a►-�n ' L7 fx
Building Inspector
6/86 and-vl
e4� awn o// BUILDING and ZONING DEPARTMENT
Bay and Haviland road, R. D. 1 Box 98
Queensbury, New York 12801
BUILDING /IINSPECTOR ' S REPORT
hIAME�
LOCATION 61
I]ate E��✓ Permit No .
✓ = -
Footing/Pier Forms APPROVED YES NO
Foundation
Waterproofing
Backfill
/ACFraming
Roofing
Siding
Masonry Veneer
Rough Plumbing
Relief valves
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 NSP,ECTION
DRIVEWAY APPROVAL
Final Building Survey
Next scheduled inspection (call when ready )
Remarks-
Q2§45� JV� krT P4� VAJ43 (A16 AAery
Buildin Inspector
6j86 and-vl
BUILDING and ZONING DEPARTMENT
Bay and Haviland Road. R. D. 1 Box 98
Oueensbury, New York 12801
BUILDING INSPECTOR ' S REPORT
NAME
LOCATION �7 n
DateA d / Permit No .
r Footing/Pier Forms APPROVED YES NO
u"oundation
Ala terproo f ing
LAKc'kf111
Framing
Roofing
Siding
Masonry Veneer AO
Rough Plumbing
Relief Valves
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 Surveyr
Next scheduled inspection (call when ready
Remarks-
Building Inspector
6/86 and-vl
�.lo+wn of Q"eFvrsbttry
BUILDING and ZONING DEPARTMENT
Bay and Hai€land Road, R. D. 'I Box 98
Oueensbury, New York 12801
BUILDING INSPECTOR ' S REPORT
NAME �rd
C►^ a J�
LOCATION -- PA
P I S+ei LT 'rllLL
Dat � �e/5 � _ Permit N . `F
✓ = -
FootingfPier Forms APPROVED NO
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
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 when ready )
Remarks-
/ u�v csc► � - f v K � ovr. AFCo
$ 1 ing s e or
6/86 and-vl
BUILDING DEFT, COPY OF APPLICATION FORM 46-EL, NEW YORK BOARD OF FIRE UNDERWRITERS.
FILE THIS COPY WITH BUILDING DEPT. WHEN REQUIRED.
w DATE
3
CITY OR
VILLAGE L'` C"�-L'�i rdrrN$HIP ?�,/.
STREET ANO _
ROAD AND P - OR r{ .r.. _ COUAITY
BETWEEN 1MHAT TWO .�.� •��"� ,•�+`/ G-^P�'„,�' C
CROSS STREETS IS POLE NO.
PREMISE L TED7 r}- � /-r (� i' f'r S„ "' 'f- .
OCCUPANT'S
NAMEBUILDING
P,O OCCUPANCY f,� �� �. GOT ✓ j
AND E ADDRESS .J/ - f Y f
BSLPPLIED r,t,,,r �, -�,� TEL. ,� :,�;�:- - ► .3
BUILDING FROM THEIR / �
IS ��y OFFICE
NEW 1.13+ OLD ElIS■FOiRK F-�{ DEFECTS
NEW l.4 . ADdITIONAL ❑ REMOVED
LIST BELOW ALL EQUIPMENT WHIC" YOU INSTALLED
NUMBER OF OUTLETS L1LMPft ROCoptnclm MBRANCH
OTORS
tio" HEATERS CIRCUITS OFFICE USE
Sift Attaprt•t
dlilinp WaII RwoRl"6 Swnmh FO"dmt Beat No. T"m Eaab IYa Na A.fY. ONLY
out- E041011Ga.gw INSPECTION
aids
Sse-
bwaa
Baw.
n.wR
tat Ff.
2nd III
Slid FI-
REMARKS: LIST OTHER ELECTRICAL DEVICES NOT SET FORTH ABOVE;
130 NOT USE THIS SPACE.
This applscatiun is in twndad to cover tM aborw-tistad
VO We sothwiaed to make thr inapawtieq. ifd '+�Finatt M W i�asl W but if at riw l of insp ectw ihKe a laund wddwtional'C%U%t the few to corwr the additiw.r by the is f oiiien wVuiWAanl not abos* listwd,
512E OF ,+� I as Pcowi+.4d
MAIMS / (" FEEDERS ELECTRIC TOTAL
CHARACTER WATT$
OF WORK EXPOSED GAS TUBE SIGN
SFORMERS OF WORK TO BE CONCEALED TRAN VA
STARTED COMPLETED (NUMBERI fCAPACsVYl
SERVICE OVERHEAD Si12E OF SIGN
ENTERS UNDERGROUNd
ra<DrNG MAILER
INSPECTION REQUESTED dF SIGN
POSSIBLE ON OR AS NEAREj
AS
AVOID DELAY BY GIVING FULL AND ACCURATE FNFORMATIOW ALL SPACES NEtil1 ❑ dtb
MUST BE FILLED IN OR APPLICATION MAY BE RETURNED. DATE OF PRINT NAME g,�11D ADD,�ESS APPUCATI NAME OF ,�J / ,,..yy
APPLICANT f fC�IJ ( ;P//„r7 SIGNATURE
/y;/ f A OF APPLICANT
STREET ADDRESS �'' / ! 1 4 ✓�� / C. '(i
I
CITY OR /` �! `,•.. y -�^ 7ELEPNDMIE .�
POST OFFICE (;� �,C' f� /� f .�' "'" c7 �.F Czup
ODE _ . . C3 f LICENSE NO-
NRIEN APPLICABLE
as el (lsev, tlas) A SEPARATE APPLICATION MUST BE FILED FOR EACH SEPARATE BUILDING
i
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`h
lay
N
9 S