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1987-595 i +CERrnf gCATE OF O CCUPA ('00"Y' TOWN OF QUEENSBURY WARREN COUNTY, NEW YORK Date July' ]. , 19 i 611 I This is to cerrify that work requested to be done as shown by Permit No. 7- 5 9 5 T i has been completed. This structure may be occupied as a one—Family Dwelling Fleldview Rd . Stone ate ) L�ocarion Glens Falls Klwanis (Boces ) Owner kkko By larder Town Board l rowiv OF QvErlvsevRY � r Building & Zoning Inspector MEN I 4 BUILDING PERMIT TOWN OF QUEENSBURY No. 57-595 WARREN COUNTY, NEW YORK PERMISSION is hereby granted to 'Glens falls Kiwanis Club (Boces) .r- 1 OWNER of property located at Lot 15 Fieldview Rd . ( St oneGate Manor) Street, Road or Ave. in the Town of Queensbury, To Construct or place a O-ne—Family Dwelling 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- Ridge OWNER'SAddrassis C/0 Queensbury Hotel Ridge St . Glens Falls , N . Y . 12801 m w 2. CONTRACTOR or BUILDER'S Name Boces E w 3_ CONTRACTOR or BUILDER'S Address W G� Dix Ave . n Hudson Falls , N . Y . - Q' 4. ARCHITECT'S Narne 0 4 r7 fD S. ARCHITECT'S Address 00 fi. TYPE of Construction — (Please indicate by X) Cn o r rt ( x) wood Frame ( ) Masonry ( ? steel l 1 Orr v+ N rt ftl 7. PLANS and Specifications rD m No. 2br x b5r per plot plan , specifications and application including C ' septic system and attached 2 car garage . r�• B. Proposed Use One—Family Dwelling 7d a $5 . 00 C/O s 129 . 00 PERMIT FEE PAID — THIS PERMIT EXPIRES April 1 , tg $$ r� I 11cotion for an extension musk be made to the Building and Zoning inspector of the phi (If a longer period is required an aPP � � town of 4ueensbu ry before the axpi ration dMe.l µ. Sept . Dated at the Town of Queensbury this 9th Day of ep . 1g 87 E m SIGNED BY / /�L Cam L-� 1 a' for the Town of Queensbury I� Building and Zoning Inspector ,/�r • N�� � 0 TO BE COMPLETED BY BLDG . DEPT . Application No . c� " s _Down o/ Queenigur y Permit Issued 19 �S BUILDING and ZONING DEPARTMENT Permit Expires 19 Bay and Haviland Road, R. D. 1 Box 98 zoning Designation SEP 2 1361 Oueensbury, New York 12801 Variance No . Site Plan Review No . UILuINC's f�' CC-r3F_. L71~;P' rf k� Approved by : J A"". y .ti e"C7`. 7 APPLICATION FOR 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 ofT this-property is P . O . Address 6C.) -� Zs'✓ L-/�7rc;J f? {G+CA, ST ems.. c *`5` Tel . tJ� �� l �S // '� Property Location : t� CSI f y .,,, -C1'i l vi ids 1 c� - Tax Map Ncr . Y / 7 Street number or building lot number Subdivision name ( if applicable) Ci07 P l c' THE PERSON RESPONSIBLE FOR SUPERVISION OF WORK AS REGARDS BUILDING CODES IS * /d, ] I��C , /cam tti S L�2 C�' r �- l err c• Name -� P . O . Address Tel . No . Name of 'builder �L�i oc7 c =a Address Die K Z oki� _ Tel . 2!ie4 Name of plumber D occ--f> Address r �� J 7 Tel Name of mason �f! Cc]" Address GS/y'�;r ' `tfL� L-/ Tel . NATURE 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 . w COMPLETE INFORMATION REQUIRED BELOW . Size of property 165 ft AJ9 . 5 5' ft . Existing building ( s) SlzeA161•-QQ— ft X ft . rt PROPOSED BUILDING AND USE : Existing buildings ) Use I/? Size of new structur .z� ft X6-s ft Foundation-piarjslab/crawl/ anti /full * Proposed building , distance from property line (circle one ) Front yard � C, ft Rear yard j V £t No . of stories (habitable space ) . * ft and ft — - Side yards �{� Height ( grade to ridge) � C e ft . If on corner , setback from side street ft If residentialv no . of families ___,__^ No . of rooms ( excluding baths ) _ * OCCUPANCY INFORMATION No * of bedrooms PRIMARY BUILDING - No . of bathrooms _ One family dwelling Primary heating system EAd.2s�_- * Two family dwelling Type of fuel Multiple dwelling / Number of units No . of fireplaces to be installed_ 3grJ Permanent occupancy will a wood stove be installed? " Zz? *Transient occupancy Central Air conditioning? IY10 �. 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 Cottage Other ACCESSORY BUILDING- 044 " oloni Row Town House Detached garage/one car/ two car/ car ( CIRCLE ONE PLEASE ) Attached garage/one car/ two car/ car * * * * * * * x * * * Private storage building ESTIMATED MARKET VALUE OF Other CONSTRUCTION $ - - - - - - - - - - INFORMATION ON BUILDING SPECIFICATIONS , ON REVERSE SIDE OF THIS SHEET , TO BE COMPLETEDI Form BPA 4/66 and-vl BUILDING PERMIT APPLICATION CONTINUED - BUILDING SPECIFICATIONS : Type of construction , wood frame , fire safe Will any any second-hand or ungraded lumber be used? If so , for what ? r, Foundation wall material rcn., Thickness Depth of foundation below grade (to bottom of footing ) ' Will there be a cellar? 1I! Heated or unheated? - Floor sq. footage sq ft Will there be a basement?? Vef> Will any portion be used as living space ? A."] ( If so , what portion? sq. ft . - - Type of use? Type of roof - lope_�fla /shed/other Material of roof /'iF ,� &trZ '{,f6,n Size , wood studs "' X „ spacings"o . c , length ft . Joists ( floor beams ) 1st . floor e>q. "X /p spacing 16 "o . c . span / c/ ft . Joists ( floor beams ) 2nd . floor A2 "X /p "' spacing{ i'ro . c . span_Yft . Overlays (ceiling beams ) o . c . span Roof rafters 9IX Of spacing o . c . span ft . Roof trusses (pre-engineered) spacing ^ _"'o . c . span. -j::L_ft , Exterior wall finish Of what material ? Interior wall finish S 8 $ aano!LCAc If a garage is to be attached , describe materials to be used for FIRE ,SEPARATION : zcuL Is there to be an opening between garage and dwelling?._ _'y _ If so will a Fire-rated 3 door , enclosure , and self-closing device be provided? �? Will a flue-lined chimney be installed? N C, ki-i2 3deight above roof ft . Depth of chimney foundation below grade ft . Depth of fireplace hearth ft , in . j Water supply - Municipal or private well SEPTIC SYSTEM _ Distance from ANY private well ( including adjoining properties 1� 3t . (A separate application is necessary for any repair or new installation of septic system) Town of Queensbury County of warren A F F I D A V I T STATE OF NEW YORK 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 ._. _�G���r !--------------------- own owner ' s agent , arcnrrect , contractor day of 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 / '70 2 . Type of heat I { 3 . Is the building mechanically cooled ?. 0 4 . Percentage of area of windows and doors A . Over 16 % Only 1 . U 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 ? 3w 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 _ 1 j--- .3 y ? 2 . R value of exterior walls /C -.� 3 . R value of glazed area. .,r'l .� 4 . R value of doors /f - el- 5 . R value of floors over unheated spaces / +7 6 . R value of slab edge insulation - unheated slab 14A) 7 . R value of slab insulation - heated slab 9 / G�5 8 . R value of heated basement/ cellar walls ( above grade ) 9 . R value of heated basement /cellar walls ( below grade ) jt ' /V 10 . Type of insulation Co Controls 1 . Thermostat maximum heat setting D . Duct Systems 1 . Is duct system installed in unheated spaces ? YES O� a . If YES ■ R value of duct installation b . R value of duct in other areas E . P_1 size Insulation /f 1 Size of hot water or cooling carrying agent gips �f 2 . R value of ,wipe insulation F . Service Water Heating 1 . Performance efficiency ogo 0 2 . Temperature control setting maximum G . For Swimming Pool Only 1 . Maximum heating Telephone Np . or // a applicant ' s signature ) .Jlsr►n df QW&W&ROV APPLIGATION FOR SEPTTG DISPOSAL PERMIT DATE `�� I LOCATION OF PROPERTY FOR INSTALLATION � ![7_... � Telephone:t4S + 1lrr� .s �tcaYS 7 Owner's Name: ,r-- Address: - +] I _ ;, z4e,' C -5 9 [ �47� Installer's Name: S Telephone: Number of bedrooms (residential only) _ Total daily flow (compute @ 150 gal per bedroom) Topography: circle one: Flat Rolling Steep Slope ° of slope Soil Nature: circle one: Sand Loam Cla Other / Depth: _ feet i Ctround Water: At what depth? feet Bedrock or Impervious Material: At what depth? _ -� feet Percolation test: it*1eone: of requir rratein. inch.Domestic water rcle one. Municipal Well ther IF domestic water supply is a Well: feet Separation: Watersupply from. Septic absorption / +�� PROPOSED SYSTEM: Septic Tank 1 t> tV> Q gal- (minimum size: 1 ,000 gal.) TILE FIELD: Each. Trench feet / Total system length :") £eet SEEPAGE PIT(S) : Number of ^� 1 Size each feet by feet Depth or Thickness Beet Size of stone to be used # _. _ p * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * I M P O R T A N T ...Please.-.LIST NEW EQUIPMENT TO 13E INSTALLED * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * (over) Section II Septic SVstem 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 Torun of Queensbury Sanitary 'Sewage Disposal Ordinance. Signature of responsible person: Dater Town of Queensbury Building and Code Department Bay at Haviland Road Queensbury, New York 12801 (518) 792--5832 SE rTLEO 1763 . . HOME OF NATURAL BEAUTY . . . A GOOD PLACE TO LWE awn a� �iceprr s6ttre� / BUILDING and ZONING DEPARTMENT tq Bay and Havifand Road, R. D_ 1 Sax 98 Queensbury, New York 12801 BUILDING INSPECTOR ' S REPORT NAME --���012 � ., LOCATION r_r � T--�— Date__! - / /O ClT Permit No . ECG r am" Footin = APPROVED - YES * NO �j/icier Forms Foundation Waterproofing Backfi l, 1 Framing Roofing Siding Masonry Veneer Rough Plumbing Reiief valves h:xt . Porches Fi-nished Floors Interior Trim Stairs & Railings Cellar- Drain Tile Concrete Floors Plbq . Fixtures Gar . Fireproofing Doc) r closers '�mc3ke Detectors chimney INSULATION : Foundation Floors Walls Ceiling FINAL ELECTR CAL INSPECTION I)RIVEWAY APP OVALL _ �- Final Builds Survey NexC :scheduled inspection ( ea ]- i when ready ) Remark s- r Building In pectr�_ 6/86 and-vl THE NEW YORK BOARD OF FIRE UNDERWRITERS BUREAU OF ELECTRICITY 41 STATE STREET. ALBANY. NEW YORK 12207 I Application CnT ; Vo. on file ki . 1 .. It } i , T141S 10EFTTIFIES THAT only the elactrieel equiprne"t as described below and intredu,eed by the applicant named ow the above application nrambar In the premises of V r.;; : F : i..T : , KT1i I .' + I.-r: rS . T TF.1 f", rrIF 1 '0'r I ': )i � FT Ni , ; ro T:`i - N . r . in the following location; L_1 Basement LP )at Ft. Q grid Ft. '- `' T' .Seiction T 'IF Block } Lot ' r was examined on "1 i r' T 1 9 W) and found to be in compliance with the requirements of this Board. FIXTURE pXTURES RANGES CGTCTKLNti QECItS OVENS dSN WASHERS EXHAUST FANS OVELETS ECEF"TACutS $VnVCHIM MICAt4DESCII twOMSCENT OFF d1YERS FURNACE MOTORS FUTURE AIDMANCE FEES SPECIAL RECO"I TIME cuxxs I I UNIT HEATERS j mutT1-cm"m mmwas SYSTEMS AMT. K. W. CKL H. F. GA3 H. P. AMT. No. A. W- D- AMT. IJMP. AMT. AMPS. TRANS. AMT. H. r. NQ. AMT. WARS SERVNCE dSQO1INECT FIG. t3F S E R Y 1 C E AMT. AMP. rM EQLRF. 1 .a' 2W 1 X 3W 3 X 3W 3 X +LW MO. " As OF CC CQN OD Mo. Cw H44,EiG OF HI LEG No. CF HEUT1lALS Of Ir EUGn1AL OTHER ArPARATUS: ' .''1 `•.1T.� 1=: F °: �� Tif;'+�'y FCr.� C G T_ '; 1 BRANCH MANAGER Per This certificate must not be aMered in any manner; return to the office of the Board if incorrect. Inspectors may be identified by their crsdi nfioh. COPY FOR BUILDING DEPARTMENT. THIS COPY OF CERTIFICATE MUST NOT BE ALTERED IN ANY MANNER. Lvov 0/ Queenj "iry BUILDING and ZONING DEPARTMENT Bay and Haviland Road, R. D. 1 Box 98 Queensbury, New York 12801 BUILDING INSPECTOR ' S REPORT NAME LOCATION �� �l1 � . r Datee�rt No . * Jo' = APPROVED — YES NO Footing/Pier Forms Foundation Waterproof inq Backfill taming Roofing Siding Masonry Veneer Rough Plumbing Relief Valves Ext _ Parches Finished Floors Interior Trim Stairs & Railings Cellar Drain Tile Concrete Floors Plbq . Fixtures Gar , Pi refroofi Door Closers Smoke Detecto s _ Chimney INSULATION Foundation Floors Walls. Ceiling FINAL ELECTRICAL INSPECTION DRIVEWAY APPROVAL Final Building Survey Next scheduled inspection. ( call when ready ) Remarks-- 1 � f Ru ' lding Inspector G/66 and-vi + ° BUILDING and ZONING DEPARTMENT Bay and Haviland Road, R.O . 1 Box 98 Queensbury, New York 12801 SEPTIC DISPOS AL SYSTEM INSPECTION " NAME. 1_] ► " �' i f-��S -- LOCATION DATE / PERMIT NO.- SOIL "TYPE Sari 'Slay percolation est Required? YES - NO percolation rate - Min/Inch - TYPE of SYS Absorption eld , total lengtl ' Length of ea h trench --- '� Depth of tren hes ;=-AX0 ' "" •' Size of gravel .3 •�`+'' _ � - SEEPAGE PITS4N er of) Size- ft. X ft Gravel size PIPING : S ' ze Type Bldg . to tank Tank to dist. box ''� � • '��'� Dist . box to fiel Openings sealed? YE NO Partial LOCATION/SETA IONS : Foundation to ank ft• Foundation to absorption ft - Absorption t lot line ft- Separation a pits / ft. LOCATION SYSTEM ON pROPERT (circle one) Front Re - Left side - Rig t side - CanrHrxta SYSTEM USE APPROVE NO Building Inspector Ol/86 mmd vl 3 THE NEW Y© RK BOARD OF FIRE AJNDERWRITERS � BUREAU OF ELECTRICITY 41 STATE STREET, ALBANY. NEW 'YORK 12207 Date Decembe r28 , 1987 Application ,Vo. on file A Rj' f ` � 2 Q 5 2 I THIS CERTIFIES THAT 030410/ 86 i �]only the electrical equipment as described baloav and intrv:dwced by the applicant named an the above 4pplication number in the prerrafees of Ze Gle-� Fal).s Kjwaaia Club , FlelA View, Queensbury , NewYork in thefolloscing location; Basement let FT. Ynd Fl. Outside section 488toch 4 Got 13 was examtined on1 Q /2 8 /8 7 and,found to be in compliance with the requirements of this Board. FIXTURE FANS ECEFTACLE3 SWITCHES RANGES C+oONtIHG BECKS tDMENS D15N WASHERS EXNAt,IST Ot"LATS IHCANbtSY.tNT PutaRESCENT AMT. K. W. AMT. K. W. AMT. K.W. AMT. K- W- AMT. H. P. 23 48 21 3 Fr DRYERS FURNACE MOTORS FUTURE APPUAPICE POWERS ISPECIALRECOFT1 TIMECUXXSj RUt UNIT HEATERS M UtTI-oUTM DIMIMERS AMT. Ic. W. OIL N. P. GAS H. P. AMT. HO- A. W. G- AMT. AMP. AMT. ANUS- TRANS. AMT, H. ►. STSTRMS AMT. WATTS NO. OF FEET 1. ra ge #6 SERVXM DISCONNECT NO. Or ryer E R V I C E AMT, AMP. TAPE **Mr. t X 2W 1 . sW 9 x sW S x .W Na- PMC,e,CK>'kD. Or CC GOND. NO- OF HI•LEG M'I G NO. OF NEUT"AS co WGRAL j 1 200 C . B . 1 x I 4 /0 1 210 OTHER APPARATUS: FOCO t� i — Smoke Detector _ Glenn Falls Kawauls Club c /o Queenabury Hotel , R4dge street sRANCH MANIAG6R Glens FAlls , N . Y . . 12801 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. BUILDING and ZONING DEPARTMENT Bay and Haviland Road, R. D. 1 Box 98 Queensbury, New York 12801 BUILDING INSPECTOR ' S REPORT NAME ' Date!rli_-�;7 Permit NO . 4LAC5RU ✓ = APPROVED - YES NO Feting/Pier Forms4 u Fondation Waterproofing Baakfill Framing Roofing Siding Masonry Veneer Rough Plumbing Relief Valves Ext , Parches Finished Floors Interior Trim Stairs & Railings Cellar Drain Tile Concrete Floors Plbg . Fixtures Gar . Fireproofing Door Closers Smoke Detectors Chimney. INSUTAATION Foundation Floors Walls Ceiling FINAL ELECTRICAL INSPECTION DRIVEWAY APPRDV Final. Building Survey Next scheduled inspection (call when ready ) Remarks- Building Inspector 6/86 and-vl e CC/fi�b / awn a/ Queeny6ury BUILDING and ZONING DEPARTMENT Bay and Haviland Road, R.D. 1 Box 98 Queensbury, New York 12801 BUILDING INSPECTOR ' S REPORT NAME Clr,_5 lc'r r2.rz LOCATION o ¢ 7L f AM Datej,/,, Permit No . � APPROVED -- YE NO ✓ Footing/Pier Forws 1►ig e Foundation Waterproofing Backfill Framing Roofing Siding Masonry Veneer Rough Plumbing Relief Valves Ext , Porches Finished Floors Interior Trim Stairs a Railings Cellar Drain Tile Concrete Floors Plbg . Fixtures Gar , Fireproofing Door Closers Smoke Detectors Chimney INSULATION : Foundation Floors Walls Ceiling FINAL ELECTRICAL INSPECTION DRIVEWAY "PROVAL Final Building Survey Next scheduled inspection (call when ready Remarks- r Building Inspector 6/86 and-vl j � • 1 ✓ VMIi V� V/ �IF �.f ��lpf.�� BUILDING and ZONING DEPARTMENT f� C Bay and Ravi€and Road, R.D. 1 Box 98 Queensbury, New York 12801 dUV'4 DING INSPECTOR ' S REPORT NAME LOCATION. SJ'��" �G2%�e'. Date r f Pi�rmit No . 00*0 APPROVED - YE� NO opting/Pier Farms05 Foundation waterproofing 8ackfill 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 . Flreproofin Door Closers Smoke Detector Chimney INSULATION : Foundation Floors Walls Ceiling FINAL ELECTRICAL INSPECTION DRIVEWAY APPROVAL Final Building Survey Next scheduled inspection (call when ready ) Remarks- . Bu�cli.ng Inspector 6/86 and-vl BUILDING DEPT. COPY OF APPLICATION FORM 46-EL, NEW YORK BOARD OF FIRE UNDERWRITERS. FILE THIS COPY WITH BUILDING DEPT. WHEN REOUIRED. TEMP. * DATE CITY Oft • •�. VILLAGE ...i' . TOWNSHIP �� � . f k:.1 . • ;,• COUNTY STREET AND NO. OR ROAD AND POLE NO. l+ ~� f � ',�Jf'4'-,f.�-3 e.,+ -r, f ("- POLENO. BETWEEN VO4AT TWO CROSSSTREETSIS "'� PREMISES LOCATED? SECTION BLOCK LOT OCCUPANT'S BUILDING NAME OCCUPANCY OWNER'S NAME ( AND ADDRESS TE L. SUPPLIED , '] :- r 4 !-% ! !1/i.,..,.. t/ .r3�.. J }t J FROM THEIR r sl-._. . /r,+.� f I ` OFFICE BY / DEFECTS S BUILD4NG NEW . OLD ❑ IWORIC NEW ADDITIONAL ❑ REMOVED ❑ LIST BELOW ALL EQUIPMENT WHICH YOU INSTALLED NUMBER OF OUTLETS Lamp p lam}pb"" MOTORS HEATERS CIRCUIITT`$ OFFICE USE Leer ONLY tlorl Silo AtmeWt HA. Watts A.W.G. Ce+Ihly WIIM Rooap'la SirFleb Prtlderrl BramkeS Na Type Eaeb No. Eaah No, Gawe INSPECTION Out Sub- beta saw me" In F1. 211111 f I. Srd Ft. 1 a � REMARKS: LIST OTHER ELECTRICAL DEVICES NOT SET FORTH ABOVE: OO NOT USE THIS SPACE. This applicalion is ingnded to core• the above-listed aquillmem to be ilssimmted but if at elms of imPecti orl there is found idditienal aquiPmamt not above Intad, you are authorized to make Me Inspection and adjust the fee to cover the additional equipment, as preriled bV the applicant_ SIZE OF ELECTRIC SIGN TOTAL MAINS FEEDERS LAMPS WATTS CHARACTER EXPOSED GAS TUBE SIGN OF WORK CONCEALED TRANSFORMERS OF VA r WORK TO BE iNUMBERI ICAPACITYI STARTED COMPLETED SIZE OF SIGN SERVICE OVERHEAD UNDERGROUND MAKER ENTERS OF SIGN IL I fNSPECTION REOUESTED ON OR AS NEAR AS POSSIBLE I NEW OLD AVOID DELAY BY GIVING FULL AND ACCURATE INFORMATION. ALL SPACES DATE OF MUST BE FILLED IN OR APPLICATION MAY BE RETURNED. APPLICAT1 PRINT NAME AND ADDRESS SIGNATURE /' NAME OF � X..C'-. .-, 3 !"rs} I t,,.5 �--�' sa.� I� . 'C E.Lt ej X _ APPLICANT ,/) OF APPLICANT— STREET ADDRESS �r't^ / e.IIC'f���-� a � " I + /7�'�E" S,zip7Y.E,,.+LEPHONE # S�� r • '' '� +� !� CITY OR POST OFFICE f'S CS'- _"� A— 41 IL �r"T ,� CODE "z' 77"� +� WHEN APPENSE LO. ICABLE (CABLE �Olo EL (REV. I/a6) A SEPARATE APPLICATION MUST BE FILED FOR EACH SEPARATE BUILDING i l9 I I I 'I