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1987-310 i CE,R,TIFICATE OF OCCUPANCY TOWN OF C�UEEN58UR'�f WARREN COUNTY, NEW YORK Oct . 1 :. ; ±9 19 B8 Date S D DUO( P This its to certify that work requested to be done a. shown byrrss+it*�N-o• 87-310 has been completed. ` ONE FQ:4ILX DWL IIVG This structure may be wrom LOT H L S V 4 Location Te.P'fILF. LAzas>; C3wner By Carder "Town Board TOVVN OF QUEE'NSBUR.Y i i F i iy s Building & Zoning lu4�1 1 BUILDING PERMIT TOWN OF QUEENSBURY No. 87-310 WARREN COUNTY, NEW YORK PERMISSION is hereby granted to Emile LaRose ro OWNER of property located at Lot 39 Hidden Hills Drive Street, Road or Ave. r, m in the Town of Queensbury, To Construct or place a One—Family Dwelling a m at the above location in accordance to application together with plot plans and other information hereto filed an co approved and in compliance with the Town of Queensbury Building and Zoning Ordinance. 1 . OWNER'S Address is 9610 Saratoga Road Gansevoort , New York 12831 r3. CONTRACTOR or BUILDER'S NameOl = LaRose Const . m LQ o tin � o~ CONTRACTOR or BUILDER'S Address 9610 Saratoga Road Gansevoort , New York 12831 � x 0' r• a. � 4. ARCHITECT'S Name C" CA un cv e ro FPLANS 'S Address struction — (Please indicate by XI Wood 'Frame i ) Masonry I ) steel i t Specifications 28 ' x54 ' per plot plan , specifications and application including sewage system and two-car attached garage . I S. Proposed Use One-Family Dwelling �c d E S . 0 C/ o $ 108 . 00 PERMIT FEE PAID - THIS PERMIT EXPIRES January 1 19 88 (If a longer period is required an app11 cat ian for an extension must be made to the Building and Zoning inspector of the Ua town of Queensbury before the expiration date.) Dated at the Town of Queensbury this 2nd Day of June 79 87 SIGNED BY l (-� - for the Town of Queensbury, Building and Zoning Inspector TOWN OV QUEENSBURY To BE COMPLETED BY BLDG . DEPT . r �c�J �r Application No . ��fp7�C _Jneun 401 Quec�► Jt "ry Permit issued 19 MAY $ � L7I BUILDING and ZONING DEPARTMENT Permit Expires 19 � Bay and Haviland Road. R. O. 1 Box 98 Zoning Designation } BUILDING 8c CODE Dk'M Queensbury, New York 12801 Variance No . Site E evlew r n App APPLICATION FOR r : i' IS re 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 . _ -------------............ r The owner of this property is : � T /n / 1 / � 1C"� P . O. Address 7 Tel . r71� - r -T./ Tax Map Property Location ; 5 � � - z" Street number or building lot number Subdivision name ( if applicable) THE PERSON RESPONSIBLE FOR SUPERVISION OF WORK AS REGARDS BUILDING CODES IS : Na e ` P . O. Addre S Tel . No . Name of builder f � ch'� sd.l Address (' C : 1s�. �.✓ 1" / Fel . =�,Jr ' Name of plumber ;f jF Address _A d4 ' Tel . Name of mason �,' 1. �� r Address, S'� f ICY _ Tel . r'/ NAE OF PROPOSED WORK : 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 * 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 AFFECTED . * of septic disposal area . COMPLETE INFORMATION REQUIRED BELOW _ Size of property___ ft- X 4?0 ft . * Existing building ( s) Size ft X ft . PROPOSED BUILDING AND USE : * Existing building (s ) Use Size of new structure ,'r _ft X .- ft Foundation-pier/slab/crawl/partial /Tu�il Proposed building , distance from property line (circle one ) Front yard {f,(� ft Rear yard .5 ft No . of stories (habitable space ) ft r Side yards /$` ft and �' Height ( grade to ridge) 725 _ r� " ^ ft , If on corner , setback from side street ft If residential , no . of families I � Now of rooms ( excluding baths ) q OCCUPANCY INFORMATION �r No , of bedrooms 5 PRgAARY BUILDING - Now of bathrooms Cr' one family dwelling Primary heating system Ty;; r , ^ _ ;,- _ Two family dwelling Type of fuel ( 4 ltiple dwelling l' Number of units No . of fireplaces to be installed -- Permanent occupancy will a wood stove be installed? Transient occupancy Central Air conditioning?_ Business BUILDING STYLE, PRIMARY STRUCTURE * Industrial * Other Ranch Contemporary Log cabin if addition , what will use be? Raised ranch Mansion Duplex Split level Old style Bungalow rea coda Cottage Other ACCESSORY BUILDING- colonial Row Town House Dotached garage/one car/ two car/ car ( CIRCLE ONE PLEASE ) * Attached garage/one car/ two car/ car Private storage building ESTIMATED MARKET VALUE OF � 'Other CONSTRUCTION $ _ �Qf INFORMATION ON BUILDING SPECIFICATIONS , ON REVERSE SIDE OF THIS SHEET , To BE COMPLETED : Form BPA 4/86 md--vl BUILDING PERMIT APPLICATION CONTINUED - BUILDING SPECIFICATIONS : J Type of construction , wood frame , fire safe , eto .Will any second-hand or ungraded lumber be used? If so , for what ? Foundation wall material ,A/r.. _ Thickness_ Depth of foundation below grade (to bottom of footing ) Will there be a cellar? ,, ells Heated or unheated? � .yl Floor sq. footage sq ft Will there be a basemen' u -� Will any ,portion be used as living space ? V1 ( If so , what portion? f sq . ft . - - Type of use? Type of roof - sloped/flat/shed/other Material of roof Size , wood stud s" X " spacing rr ' o . c . length ft . Ioists ( floor beams ) 1st . flooru+,X /U � • spacing /�r 'f "o . c . span_,�,�`` t . .Toists ( floor beams) 2nd . floor "XL/L _L" spacing No span 2E� _ft . Overlays ( ceiling beams ) 9 "X ++ spacing-+'o . c . span_ / eft . Roof rafters .? �� spacing_ _f�o . c . span ft . Roof trusses (pre-engineered) spaci/ ng "o . c . span ft . Exterior wall finish_ L;g2Li1�. p r4 e! /Arr-r, of what material ? Interior wall finish — `f ` f If a garage is to a attached , descri},e mate is to b u ed for FIRE SEPARATION : r z S �_ 'Ciz y�"_ ,t ec Is there to he an opening bibr een garage and dwelling? 5 ; &% If so will a Fire-rated door , enclosure , and self-c using device be provided?Will a flue-lined chimney he installed? 171rc Height abo a roof ft . Depth of chimney foundation below grade ft . Depth of fireplace hearth ft . in . 7 Water supply - Municipal or private well rl SEPTIC SYSTEM _ Distance from ANY private well Un6luding adjoining properties ft . (A separate application is necessary for any repair or new installation of septic system) Town of Queensbury C County of Warren A r F I D ►4 V I T STATE OF NEW YOR,K. 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 day of Owner , o er s agent , arctaitect , contractor - lg Notary Public , Warren County , N . Y . SPECIAL CONDITIONS OF THE PERMIT : Sy TOWN OF QUEENSaURY WARREN COUNTY . NEW YORK. Application for . BUILDING PERMIT IN COMPLIANCE CVATION EEWITH THE NEW YORK STATE A permit must be obtained before beginning wade . ANSWER ALL of the following ! LAk- � 1 . Gross floor area 2 , Type of heat q 3 , Is the building mechanically cooled ? V\- � � 4 . Percentage of area of windows and doors _ AV A , over 16 % Only 1 . U value Of gross ar oea of walls , roof / ceiling and floors exposed to ambient conditions 2 . Floor over heated spaces YES NO a _ Are foundation walls insulated ? YES NO I . 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 g , Under 16 % Only roof and floors e posed to ambient conditions 1 . R value of 2 . R value of exterior walls 3 , R value of glazed area 4 , R value of doors 5 , R value of floors over unheated spaces 60 R value of slab edge insulation - unheated slab 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 ) ti la . Type of insulation ' t> C . Controls 1 .Thermostat maximum heat setting DO Duct Systems aces ? YES NO 1 . is duct system installed in unheated sp a . If YES . R value of duct installation b . R value of duct in other areas E , Piping Tnsulation ent pipe 1 . Size of hot water or cooling carrying ag 2 . R value of pipe insulation F . Service Water Heating °Co 1 . Performance efficiency ` 2 . Temperature control setting maximum„ G . For Swimmin Poo ] Only 1 . Maximum heat,In`g Telephone NO . __/ ��+� ( apP t " s signature ) APPLICATION FOR SEPTIC DISPOSAL PERMIT DATExr ^ / LOCATION OF PROPERTY FOR INSTALLATION M Oriir Q ✓a�el 1� ,Y �j Tel ?�.� Owner's Name: .,. �� ,�,n A l : nC� - / Address: �'�! ` �" '�� Installer's Name: Telephone: /� ��'— � Y22 Number of bedrooms (residential only) Total daily flow (compute @ 150 gal per bedroom) C t � Topography: circle one: Flat Rolling Steep Slope of slope Soil Nature: circle one Sand Loam Clay Other / Depth: feet Ground Water. At what depth? feet Bedrock or Imp4Ewvious 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 000 gal. (minimum size : 1,000 gal.) TILE FIELD: Each Trench feet / 'Total system length 21016 feet SEEPAGE PIT(S)4 Number of / Size each feet by feet Size of stone to be used, # ' / Depth or Thickness / °> r feet IMPORTANT ...Pl,ease...LIST NEW EQUIPMENT TO BE INSTALLED (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, the 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 $250.00. C. An approved copy of the plot plan shall be available on the construction site. Failure to produce said plot plan at time of inspection may result in an immediate work stoppage. D. Should. unforeseen problems during construction prevent proper installation, alteration or repair of an approved system, a new proposal must be submitted to the Queensbury Building Department before further construction. I have read the regulations above and agree to abide by these and all requirements of the Town of Queensbury Sanitary Sewage Disposal 01dinance. Signature of responsible person: Date: Town of Queensbury Building and Code .Department Bay at Haviland Road Queensbury, New York I Z801 (518) 792-5832 SETTLED 1763 . . . HOME OF NATURAL BEAUTY . . A GOOD PLACE TO LIVE r' g LDING and ZONING DEPARTMENT nau nd F-Iaviland Road. R.D. 'I Sox S$ F � � ueenstiury, New York 12507 i ILDING INSPECTOR ' S REPORT INANIE _ �L - r r LOCATION Date_ '�u f _ Permit No . M/ APPROVED - YES NO Footing/Pier Forms Foundation Waterproofing gaackfill Framing Roofing Siding Masonry Veneer Rough Plumbing Relief Valves Ext . Porches Finished Floors Interior Trim � . stairs & Railings Cellar Drain Tile Concrete Floors Plbg . Fixtures or Gar . Fireproofin Door Closers smoke Detector Chimney INSULATION -. It Foundation Floors Walls Ceiling FINAL ELE RI AL INSPECTION��� . I)RIVEWAY PI'ROVAL Final But ding Survey Next scheduled inspection (call when ready ) Remarks- httiF K eGFG / JS j9 p-^tt/1 G� I 1?`h Wla fe s �C building Inspector 6/86 and-vl THE NEW YORK BOARD OF FIRE UNDERWRITERS BUREAU OF ELECTRICITY FiLG 41 STATE STREET, ALBANY. NEW YORK 12207 Date APRIL LS . 1988 Application No, on file G13793/ 87 M A 7 1- 14 9 3 4 THIS CERTIFIES THAT' &My the electricol e4uipme»t s describod begawo and Introduced by the oPPti'I ant named am the above a appUcssi'on Plumber in the Pra"Od +t of i: :ILE AROSE, LSAT �,, gILLS ;)RIVE , C HIDDEN HILLS ) t QUFENSBURYe N1!W YIJ:W OUTSIDE in the following location.: � Basement � lat Fl. E1 93 � 3 Bnd Fl. .Section Block Lot toas examined on 4/ 1 3 / 6 3 and found to be in compliance with the requirements of this Board. FIxTURE RXTURES RANGES COOKWM DECKS OVENS DISH WASHERS EXHAUST FANS OUTLRTS ECEF'TACLES SWITCHES INCAWOtsCt NT FLUOlESCENT AMT. K. W. AMT, K- W. w T. K.W. AMT. F- 3 �R 28 4€3 18 DRYERS FURNACE MOTORS FUTURE AMUANCE FEEDERS SPOCIAL RRC'FT UME CLOCKS went. K. W. OIL M. P. OAS N, r- T. . 0. NxT. AAV. AMT. AlMrS. TRANS. AMT. N. r. AMT_ wAtTS 1 I-1WT # 10 1 I 1�ftYH # 1 O E R Y 1 E SERVICE DISCONNECT NO.OF S METER No. of CC. COND, A. w_ O. NCL, CI nl- 'N a' NO. OF NtUTRA15 p�I W. G-Ld AenT, AMP, IYFF E�LteF, 1 .e' 3W T AV 3W 3 M 3w 3 X 4W FER Ir OF CC. coma. MI-LEG 3 �rJ[ Cfs 1 1 . 4 /0 1 2 / C3 OTHER AFFARATUSe '— SMOKE DETZCTOR ELECTkIC RO02'1. HEATERS 3— 2 . 5 Kw 2— : * U Mw 4� 1 . 5 1Qv4 S— 1 . 75 Kw 2- 1 . 0 KW i b 2 BRA ODWAY AlF VOAT UDWARD t NEW YORK 1282.8 239 BRANCH MANAGER Per This certificate must 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. �` _ /own o� eeeeri lhssre� BtJILD1NG and ZONING DEPARTMENT Bay and Haviland Road. R.D• i Box 98 CTueensbury, New York 12801 BUILDING INSPECTOR ' S REp+ORT NAME LOCATION wd5p .i', Date /r �� j Permit No . 9 7 3 } e7 APPROVED _ YEAPPROVED Footing/Pier Forms Foundation Waterproofing ]Backfill '�,''raming Roofing Siding Masonry Veneer J, ue3h Plumbing Relief Valves Ext . porches Finished Floors Interior Trim Stairs & Railings Cellar Drain Tile Concrete Floors Plbg . Fi.xture s Gar . Fireproofing Door Closers Smoke Detectors Chimney VN SU LA`S I ON Foundation Floors r Walls Ceiling FINAL ELECTRICAL INSPECTION .M DRIVEWAY APPROVAL Final Building ---- ready ) Next sched,sled insp ec (call sateen R.emarks- Building Inspector 6/86 and-vl rrig , OttI�7 ll BUILDING and ZONING DEPARTMENT ! Bay and Haviland Road, R.D. 1 Box 98 Queensbury. New York 12801 SEPTIC DISPOSAL_ SYSTEM INSPECTION LOCATION DATE I� ��-�- PERMIT NO . E : 3�/o SOIL TYPE - and L - Clay Itec;nired? YES Percolation _ 'Min/Inch ' Percolation rate TYPE of SYSTEM_ Absorption field , total length'./.! � Length of each trench Depth of trenches_--�-- Size of gra el T . .-f -----� SEEPAGE PIT .(Number , Size- f - x - Gravel size Size 'type PIPING Bldg , to tank 1r Tanis to dist . ]S Dist , box to f eld/ i ( e V 5 NO Partial Openings Seale LOCATION/SEPARAT Foundation to tankft . t i On Foundation to ab ��ft ' li e Absorption to 1 fto SeparatlOn of its OPERTY (circle one) LOCATION STEM ON _ Left Sid ow Right side Front - $ - COMMENTS : SYSTEM USE APPROVED YES NO Building Inspector i 01/86 and vl _low+t o� �+�teers .3 � sere�[ BUILDING and ZONING DEPARTMENT Bay and Haviland Road, R.D. 1 Box 98 {Queensbury. New York 12801 SEPTIC DISPOSAL SYSTEM INSPECTION NAME LOCAT IONS_ DATE ERMIT NO . SOIL TYPE - Sand - Loam - Clay - Percolation Test Required? YES Na Pexcolation rate - Min/Inch TYPE of YSTEM: Absorpti n field , total le th Length o each trench r Depth of Tenches Size of g avel SEEPAGE PI S4NU'nber of) — Size� x - Gravel size —"Type PIPINGS Size Type Slag . to tan ,S V -` Tank t[7 d1St . X Dist, box to f I / ES NO par-t.ial Openings sealed LOCATION/SEPARA I S : Foundation to ants �ft. Foundation to Asor Lion f t. Absorption to lot li ft. Separation 4 '4ts LOCATION OF CiN P OPERTY (circle one) - Left side`' .- Right side Front Rea - CCMMENTS : SYSTEM USE APPROVED ,7 Building Xnspector 01/86 and vl BUILDING and ZONING DEPARTMENT Bad (7 eenSbu N w YW a12801 98 L BUILDING INSPECTOR ' S REPORT NAME LOCATION I Permit Now Date * « +� IN : ,*'APPROVED* -* YES NO Footing/Pier Forms Foundation Waterproofing sacy,f ill Framing Roofing Siding Masonry Vene r Rough Plumb! 9 Relief Valve Ext , Porches Finished Floo s Interior Trim Stairs & Rail ' 9 Cellar Drain `!•' e Concrete Floor Pl'bg - Fixture �--- AGar . Firepro in Door Closer ----� Smoke Dete ors Chimney IN SU LAT I Foundat ' In Floors Walls Celli FIN TRICAL INSPE ION DR-IV AY APPROVAL rvey Final Building 13ext scheduled insp action C all when ready ) Remarks- ,[' ,Pe4::�ejt ' t Sui g nspect r 6/86 and-vl 3 - � BUyI i31h1Ca and Z0Njt4G DEPARTMENT Bay oueensbury. New Yorkid �128011x 98 BUILDING INSPECTOR ' S REPORT NSPECTOR ' SREPPORT NAME JM �f iIII LOCATION • }C� "_`" rr �i Permit 1� O pate = ---� * * * * * * * No noting Pier *arms Foundation Waterproof ing Sackfill 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 IN SU LAT 10N Foundation Floors Walls Ceiling �- FINAL ELECTRICAL INSPECTION�� DRIVEWAY APPROV Final Building Survey - ---- - Next scheduled snap action (call when ready ) Remarks'" Building Inspector 6/$6 and-vl � 0t4l" of Que+ensiury BUILDING and ZONING DEPARTMENT Bay and Havitand Road, R.D. 1 Box 98 pueensbury. New York 12801 13uILDING IN5PECTOR ' S REPORT NAME t 1 LOCATION ►I permit NO4 4* FIppRC7VEL7 - YES NO F oting/pier Forms o undation nterproo € ing Sack€I ll Framing Roofing Siding Masonry Veneer Rough plumbing -�"-�- Relie € Valves Ext . porches Finished Floors Interior Trim Stairs & Rail-Ings Cellar Drain Tile ~� Concrete Floors plbg , Fixtures Gar . Fireproofing Door Closers Smoke 'Detectors Chimney INSU L.RT2pN : Fnundation Floor's walls Ceiling FINAL ULECTRICAL INSPECTION I)RIVEWAY A£"YRUV � --- Final B.,11ding Sur tTeY Next sch eduled inspection {call when ready) Remarks- tAj An- :Iej *T Building Inspector 6/66 and-vl lOwn 01 Queen $ eere� BUILDING and ZONING DEPARTMENT Bay and Hav►iland Road, R.O- i Box 96 Queensbury, New York 12801 BUILDING INSPECTOR ' S REPORT NAME LOCATION Date & / permit No . APPROVED - YE5 NO Footing/Pier Forms�� Foundation Waterproofing Sackf ill F ramming Roof ing Siding Masonry veneer Rough Plumbing Relief Valves -- �- Ext . Porches_ Finished Floors Interior Trim Stairs & Railings Cellar Drains Tile Concrete Floors Plbg . Fixtures Gar . Fireproofing Door Closers Smoke Detectors Chimney INsuLATION : Foundation Floors Walls Ceiling FINAL ELECTRICAL INSP-ECTION DRIVEWAY APPR.OVAI _ Final Building Survey Next scheduled inspection (call when ready ) Remarks- Building inspector 6/86 and-VI BUILDING DEPT, copy OF APPLICATION FORM 46-EL, NEW YORK BOARD OF FIRE UNDERWRITERS. FILE THIS COPY WITH 1UILDING DEPT. WHEN REQUIRED. TEMP. lIl Ip1IlTE C. CITY OR ---- VILLAGE M1 •" Co TOWNSHIP STREET AND NO. h h . ROAD AND POLE NO. BETWEEN WHAT TWO • POLE NO CROSS STREETS IS I frr / f PREMISES LOCATED? r ° / ' / SECTION !BLpGK LOT OCCUPANT'S BUILDING NAME ``V ; i r C OCCUPANCY 7y.i t r ...- •,/-- .'r . f f OWNER'S NAME AND ADDRESS i A r iCURRENT i:F _a+,t TEL. # 7 ,r. ti 3r•..- SUPPLIED I / ,� BY �+ ; , A (0 FROM THEIR '. %.,o r�/.+-' / ,�/'r" OFFICE IBVILffING {. NEW 1 OLD ❑ WWORK NEW Roo AODITIONAL ❑ REM*V.. ❑ LIST BELOW ALL. EQUIPMENT WHICH YOU INSTALLED NUMBER OF OUTLETS No. of Fl%turas '& BRANCH Laa:a- Lamp Reaptwdar MOTORS HEATERS CIRCUITS OFFICE USE ONLY lion Bide AttasI It H.P. Wefts A W.G.CNllnp Wall Ree+pFAR S'oi1 Pendent Sredlcet No. TYPe EachNo. Eeah No. INSPECTION two skM Sub- bass Brs• ntr.rt list Fl. Zed FI, $rd Fl, t REMARKS; LIST OTHER ELECTRICAL DEVICES NOT SET FORTH ABOVE - QO NOT USE THIS SPACE, This application is in Mn(I4d to cover the atidv •listed *w ipment to be it spscled but if at time of inapsction there is found additional equipment not abOY! ii#Red, You are authorized to make the impaction and edjmt the fee to Ro+rb the add;ti Onal equipment• as provided by the applicant. 512E S ELECTRIC SIGN TOTAL MAINS FEEDERS LAMPS WATTS CHARACTER .MM' SED GAS TORE SIGN OF WORK "�r- ., , .CONCEALEL} TRANSFORMERS OF VA TO BE STAR NUMBER) 4CAAACITY1 STARTED COMPLETED f IZE. OF SIGN SERVICE AVER VNDERGRQUN ENTERS .f�"�.- MAKER EE II I�IIII 1L 1 OF SIGN CPINO�O AE NEAR AS STED NEW © OLD AVOID DELAY BY GIVING FUL AND ACCURATE INFORMATION. ALL SPACES MUST BE FILLED IN OR APPLICATION MAY BE RETURNED, gPpLIGATION PRINT NAME AND ADDRESS r % NAME OFa APP. G•t SIGNATURE f OF APPLICANT STREET AL?DR0S.. M'� /I [- t• I' {i ✓ ! TELEPHONE zip P IT T;QFFICE r r .z ! �� CUDE f:•,/l'r^r�F' I LICENSE NO. + WHEN APPLICABLE 4 tEL (REV. , . 1) A rSEPARATE APPLICATION MUST BE FILED FOR EACH SEPARATE BUILDING S I N W N M, 9 � N 12 0' U 7 J J IJ N1000EtJ 4tu_S SobDwcSuw-Loll39 L4 (Los-- 2GSt DE1x i 5e LLE X,: It o'