Loading...
1987-682 r` i ' CERTIFICATE E OF C TJPANC1Lr TOWN OF QUEENSBURY WARREN COUNTY, NEW YORK Date July 14 , 19 This is to certify that work requested to be done as shown. by Permit No. 87--682 has been completed. This structure may be occupied as a One. Family Dwelling Location 0svner Fred & Barbara Champagne By Order "Town Board TOWN OF QUEENS$URY _ r ,• �r,,�Ff/ �,I{• d '.4ea .r-� T ems...... - -• Building & Zoning Inspector BUILDING PERMIT � TOWN OF +QUEENSBURY No 87-682 z WARREN COUNTY, NEW YORK :p PERMISSION is hereby granted to Fred & Barbara Champagne I OWNER of property located at Sunnyside North Street, Road or Ave. 0;� in the Town of Queensbury, To Construct or place a One—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. 1 . OWNER'S Address is ri Box 343 Juniper Dr . Glens Falls , N . Y . 12801 Q to w 2. CONTRACTOR or BUILDER'S Name "t Or 4Q Same w n a' 3. CONTRACTOR or BUILDER'S Address w TJ B w ' oq w to 4. ARCHITECT'S Name v5 5. ARCHITECT'S Address tC to r P- ro 5. TYPE of Construction — jPlease indicate by X) oz H ry I xi Wood Frame ( } Masonry i I steel I T a' 7. PLANS and Specifications No. 32 ' 4" x 56 ' per plot plan , specifications and application including septic system and attached two car akitasi>t garage & driveway permit S. Proposed Use One-Family Dwelling rho 1 F-4 $5 . 00 C/O tc $ 122 . 00 PERMIT FEE PAID — THIS PERMIT EXPIRES May 1 , 19 88 d (lf 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.) 9th October 87 °a Dated at the Town of Queensbury this y� Day of 19 SIGNED BY 7 C�- `' '"a' for the Town of Queensbury -- Building and Zoning Inspector - r TO BE COMPLETED BY BLDG . DEPT . a�] Application No . wn oueen3ure Permit Issued 19 BUILDING and ZONING DEPARTMENT Permit Expires Bay and Haviland Road, R. D. 1 Box 98 Zoning Designation Queensbury, New York 12801 variance No . Site Plan Review No * OCT b 1987 ✓ Y Approved by11014� f ° , APPLICATION FOR �� G� `7 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 r cG' G' - r C .^.rF cp/ _____Tejo ;?%' 3' lers7S P - O. AddresS� J7 ` + r?�!sl"',r� / -- �- Property Location :- rt_�r� L/ 6 6 ` Tax Map Na . f / Street rAimber or building lot number Subdivision name ( if applicable) THE PERSON RESPONSIBLE FOR SUPERVISION OF WORK AS REGARDS BUILDING CODES IS : yme / P . O . Address r Tel . No , of builder T?� b L h p,,,AT� Address Name of plumber Address Tel . Name of mason Address 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 wont (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 306 ft - Existing building ( s ) Size - ft X - ft . PROPOSED BUILDING AND USE : * Existing building ( s ) Use r N * . Size of new structure �ft X :5-� ft Fe>undation-pierfslab/crawlfpartial u 1 * Proposed building , distance from property line * oe (circle one ) * Front yard ft Rear yard /' �,� ft No . of stories (habitable space) Z Side yards ' ft and 443 or ft Height ( grade to ridge ) 4f ft * if on corner , setback from side st eet ft If residential , no . of families No . of rooms ( excluding baths ) * OCCUPANCY INFORMATION No . of bedrooms �i �_...,,^^ * PRIMARY BUILDING - Noe of bathrooms � One family dwelling Primary heating system . s e . i Two family dwelling Type of fuel - Multiple dwelling / Number of units No . of fireplaces to be installed / * Permanent occupancy Will a wood stove be installed? ./X/Q 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 ;Cape Cod Cottage Other SW-I- gpK ACCESSORY BUILDING- Colonial Raw Town House Detached garage/one car/ two cart ear ( CIRCLE ONE PLEASE } Attached garage/one car/ two car/ Z car * * * * * * * * * * Private storage building ESTIMATED MARKET VALUE.-__ OF Other CONSTRUCTION 760 TNFORMATION ON BUILDING SPECIFICATIONS , ON REVERSE SIDE OF THIS SHEET , TO BE COMPLETED ! 7rm BPA 4/86 and-vl UIEDING PERMIT APPLICATION CONTINUED - BUILDING SPECIFICATIONS : Type of construction , wood frame , fire safe , etc . Will any second-hand or ungraded lumber be used? if so , for what ? ' .-. .. Foundation wall material �'"c .� ,.�. � fog- Thickness Depth of foundation below grade (to bottom of footing ) will there be a cellar?_ ��Heated o unheate Floor sq. footageli/4nj � sq ft Will there be a basemenf ? t141 Will any portion be used as living space? ( If so , what portio ;h sq , ft . - - Type of use? Type of roof slo e flat/shed/other Material of r of Size , wood studs^ "'X�`"' spacing" & '"o . c . length 3G/�f't . � '^ Jolsts ( floor beams ) lst . floor ,"X- -� � spacing,•JJ,_"'o . c . span ft , .joists ( floor beams) 2nd . floor ^�_"X_1 -"' spacing_,,_(C�"'o , c , span ft , Overlays (ceiling beams ) c�"' s acing "o . c . span ft . Roof rafters '"X� spacingo . c . spanft . Roof trusses (pre- engineered) spy cink " o . c . span17 `- +�+rft . Exterior wall finish *k3 WI rRre E'c} �}� Of what material? (AjkA- le cep A9, Interior wall finish 112 + ' If a garage is to be attached , esc ibe Jaterials to be used for FIRE SEPARATION : � e - Its 4f Y� , � e7by-u _ Is there to be an opening between garage and dwelling? (A CS If so will a F_ire-rated ^ door , enclosure , and self-closing device be provided.? (r—� Will a flue-lined chimney be installed? //0 Height abov roof ft . Depth of chimney foundation below grade ft . Depth of fireplace hearth ft & in . Water supply - Municipal or private well 1�1 u _ SEPTIC SYSTEM _ Distance from ANY private well ( including adjoining properties �l,4,01 ft . (A separate application is necessary for any repair or new installation of septic system) Town of f Wayrbury p F c I D p V T T STATE OF NEW YORK County of Warren 1-t i rl 1 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 THISSignature , -_ _Y_ Owner , owner ' s ge trf arcnitect , contractor day of 19 Notary Public , Warren County , N . Y . SPECIAL CONDITIONS OF THE PERMIT : By-------------------------- ------------. TOWN OF QUEENSBURY WARREN COUNTYr 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 : r 1 . Gross floor area 2 . Type of heat..� c ..f7 ''rC 3 . Is the building mechanically cooled ? /YCS 4 . Percentage of area of windows and doors / Ce J rL�' 4 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 pexposed to ambient conditions_ 2 . R value of exterior walls 02 ,24 4 3 . R value of glazed area - y4mf". 4 . R value of doors 5 . R value of floors over unheated spaces 6 . R value of slab edge insulation -- unheated slabC ,r► � 7 . R value of slab insulation - heated slab art e)y) de 8 . R value of heated basement/ cellar walls ( above grade ) 9 . R value of heated basement /cellar walls ( below grade ) 10 . Type of insulation }—, = s^ lr, 12 1�rc{�c���,_� � �-� �^H C . Controls 1 . Thermostat maximum heat setting Do Duct Systems 1 . Is duct system installed in unheated spaces ? YES 40 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 . ( applicant ' s i ature ) APPLICATION FOR. SEPTIC DISPOSAL PERMIT DATE LOCATION OF PROPERTY FOR INSTALLATION Owner's Name: Y .s-rt, .Rc Telephone. T t.� y '- ++�/ 7,J'"� r' Address: -►, „� �'y " �� Installer's Name: Telephone: Number of bedrooms (residential only) _ 3 Total daily flow (compute @ 150 gal per bedroom) ASO Topography: circle one: Flat Rolling Steep Slope % of slope Soil Nature: circle one: San Loam Clay Other / Depth: feet Ground Water: At what depth? feet Bedrerck or Impervious Material: At what depth? _Wot, r— feet Percolation test: circle one: not required required / rate min, inch. Domestic water supply: circle one: Municipal ell Other IF domestic water supply is a Well: Separation: Watersupply from Septic absorption . AS b feet PROPOSED SYSTEM: Septic Tank _ gal. (minimum size: 1 ,000 gal.) TILE FIELD: Each Trench feet / Total system length feet SEEPAGE PIT(S) : Number of / Size each feet by feet re �- Size of stone to be used # , / Depth or Thickness / Z ZG/ feet IMPORTANT ...Please...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, 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 al1 requirements of the Town of Queensbury Sanitary Sewage UUposal C7rdinance. Signature of responsible person, i2�_ ct Date: ,r Town of Queensbury Building and Code Department Bay at Haviland Road Queensbury, New York 12801 (518) 792-5832 SE fTLED 1763 HOME OF NATURAL BEAUTY . . . A GOOD PLACE TO LIVE flown o/ �uekn3 � ur� I BUILDING ING and ZONING DEPARTMENT Bay and Haviland Road, R.D. 1 Box 98 Queensbury, New York 12801 JJ�l BUILDING INSPECTOR ' S REPORT NAME LOCATION all Date 2/q / Permit N0 APPROVED - YES NO Footing/Pier Forms Foundation Waterproofing Backfill Framing Roofing S id i.ng Masonry Veneer Rough Plumbing Relief Valves . Ext . Porches Ll Finished Floors interior Trim ,,e' airs & Railings Cellar Drain Tile -- Concrete Floors — Plbg . Fixtures" l� Gar , Fireproofing Door Closers Smoke Detectors Chimney INSULATION Foundation Floors Walls Ceiling FINAL ELEC RICAL INSPECTION_�� DRIVEWAY PROVAT Final Bull ing Survey Next scheduled inspection (call when ready ) Remarks- . Bull i g Spector 6/86 and-vl r THE NEW YORK BOARD OF FIRE UNDERWRITERS BUREAU OF ELECTRICITY FNLG 41 STATE STREET. ALBANY. NEW YORK 12207 Date AUGUST 4 , 1988 Application No. on file 029612 / 87 A 723042 THIS CERTIFIES THAT only the electrical egtsiptnetnt ae described below and introduced by the applicant nanned on the above applscation narnber i» the pre,nisea of FRET} CHAMPAGNE , SU14NYSIDE NORTt1 , QUEENSBUR.Y , NEW YORK inthefollowinglocat'on; II Basement latri. � 2nd FT. GARAGEIATTIC Section 49 Black I ,Got 6 was examined on 7 Y13/ 88 and found to be in cornptionce with the rega.iremcnta of this Board• r pXTURE F1ILTURES RANGES COOKIP/4 DECKS OPENS dSH WASHERS E7CHAUST FANS OVTLIFTS AC'iES SMFLTCHES aNCANc*$CENT Fu,aaYt3CEM AMP, K. W, AMT. K. W. AMT. K.W. AMT. K. W. AMT. M. r. 23 45 19 1 4 / 8 3 FR DRYERS FURNACE MOTORS FUTURE APPLIANCE FEEDER'S SPECIAL RSCA PTJ TIME CLOCKS BELL UNIT HEATERS MULTI-OUTLET DIMMERS SYSTSMS AAAT. K, W, qa{ H. P. GAS H_ P, AMP. IV13. A. W. G_ AMP. AMP. AMP. Am". TRANS. AMP. H. ►. I T AMP. WAT'a5 1 SERVICE DISCONNECT NO. OP S E R VT I C E MST. AMP. TYPE M� 1 JI 2w 1 A' 3w 3 .M 3w 3 x AW NO' O''E�CC�COI OF CC CONO. . OF FIMLEG OF•H� I'm N0' OP NEUTRMs OF NEUGniAI 1 200 Cb x 1 4 /0 � 1 2 /0 OTHER APPARATUS: 3~ GFCI 2— SMOKE DETECTORS 4- 1 . 6-- 47 4 0 — 1 — KGi it F RED CHAMPAGNE �? " BOX 343 JUNIPER DgIVE GLENS FALLS , NEW YORK 12801 239 BRANCH MANAGER r Per This certificate must not be altered in any manner, return to the office of the Board if incorrect. Inspectors may be identified by LFiar credentials. COPY FOR BUILDING DEPARTMENT. THIS COPY OF CERTIFICATE MUST NOT BE ALTERED IN ANY MANNER. �! ��rr ; 4reeenshtsry ; y E own o T i; k ¢ l7LLCi11+1G and ZONING S3EPAFt7MEh1 r 4 t/a 1 `B 1 Box 9B FF ay and Haviland Road. R.D. r pueensbWYI Nev" York 12801 1let I NS P 'ECT'O'R ' S REPORT ` i BVILS3ING ,- ,I� NAME y LOCATIONS r7 ri pis t No . Permit Dalotte f✓ `' * * * • * * NO * * * * s APPROVED - YES Footing/Fier Forms Foundation waterproofing Back.f i l l ti Framing Roofing Siding Masonry Veneer`�_�-- ---J' Rough Plumbing,.��-- [/ Relief valves g.xt . Porches Finished Floors Int-erior Trim stairs & Railings Cellar Drain Tile Concrete Floors �'1} g • Fixtures v ` Gar . Fireproofing Tyocar Closers 1 1 make Detectors`__�_�_ i Ch I MD eY i SFSSi3I.A'I'1C3[3 : Foundation Floors 1 walls 4. { Ceiling FINAL ELECTRICAL Il35PEC'1In �. DRIVEWAY APPROVAL Building survey �--� � Final 1 l eCtian (call when ready ) Next sched l uled insP f t Remar4rs- /.ter / t fro c Yc k ,x VLN I - i vi ding Inspector G/B6 and-vl Qupenyeerr� and ZONING c)���T�ox 9S EN Bay and ensbu nd N York 12801 Queensbury, BUILDING INSPECIOR ' S REPORT NAME LOCATION / permit. N� . Date t ' APPFROVED - YES No Footing/pier Forms Foundation waterProof� g ckfill naming Roof ing Siding ding �onry u Veneer _— gh Pluv1b1ng —Relief Valves____ Ext , Porches Finished Floors Interior Trim Stairs & Railings Cellar Drain Tile Concrete Floors P3-bg , Fixtures Gar . Fireproofin Door Closers smoke Lletectors Chimney �i3SULA`rIL]13 = Foundation -� N4voors %. yE,walls „_„ $& Ceiling CAL Il3SpECT''10N �--- F'IPIAL ELECT L3RIVEWwild �oVAL ng survey ~-. Final cheduI inspection I call when ready ) Next s f ' "pt'�G RemarkPt� _ T�y C� Z��. 71 �,q or a ui.ldin Inspector B 1-VI ",f,own o� '�ueen3t>' serc� VIA 13UIt DI aG and ZONING [DEPARTMENT Bay and Haviiand Road, R.Q. I Sox 98 oueensbury. view York 12801 SEPTIC DISPOSAL SYSTEM INSPECTION NAME. if.i Q LOCATION / r [��j / r) PERMIT N0 . 40 L " DATE SOIL TYPE - Sand - Loam - clay - -� Percolation Test 'Required? YES - . NO Percolation rate - Min/Inch - TYPE of SYSTEM: total length 2, Absorption field , �- Length of ea h trench Depth of tren hes Size of gravel er of) SEEPAGE PITSN f t. size- f t. x _ Gravel size Sizs 'rYPe PIP ING : Bldg . to tank -- � -- Tank to list . box Dist. box to field/ NO Partial Openings sealed? YES I,OCA,TIDN/SEPARATI(>NS : 2,, ft Foundation to tank Lion Foundation to abso ft. p,bsorption to lot in'e ft. Separation Of pit � PROPER (circle one) ION OF SYS - Ri t side - ront Rear ft side C S = T-1 & t" SYSTEMUSE APPROVED ES NO Building In actor 01/86 and v1 cC'� Queenjl urV J'r� cvr7 0 Owl � r ! ,gr'' � �1 gUlLlJlhlCa and Zdh11'NG DEPARTMENT a and Haviland Road . R, D- I Box 9B Queensbury, NeW York 12801 10 UILDING INSPECTOR ' S REPORT NAME LOCATION .� � L7ate Permit NO + AppR7VET) ^* YES* Footing/Pier FormsL"WjjrG //i�,2i4dr� ndation ,"aterproofing Backfill Framing Roofing siding Masonry Veneer Rough plumbing Relief Values Ext . porches Finished Floors Interior Trim Stairs & Railings Cellar Drain Tile Concrete Floors Plbg . Fixtures Gar . Fireproofi Door Closers Smoke Detector Chimney INSULATION : Foundation Floors Walls Ceiling FINAL ELEC RICAL INSPECTION �,.... 1]RIvFWAY A R©VAL Final Boil ing survey Next scheduled inspection (call when ready ) Remarks- or if, Bull ' ng Inspector €,/B6 rnd-VI [ 4 BUILDING and ZONING DEPARTMENT 111[+ !! Bay and Haviland Road, R.D- 1 Box 98 Queensbury. New 'York 12801 B f CDING INSPECTOR ' S REPO NAME - V/"Z.XW LOCATION 5r1r!�2'/ Date ,✓1 / - Permit No . APPROVED - YES NO 1!5oti.ng/Pier Forms /, r� — Foundation55e�� Waterproofing Backfill Framing Roofing Siding Masonry Veneer Rough Plumbing Relief Va1v s Ext . Porches Finished Floo interior Trim Stairs rx Railin Cellar Drain Tile Concrete Floors Plbg . Fixtures Gar . Fireproofing Door Closers Smoke Detectors Chimney INSULATION : Foundation Floors Wa 1 l s Ceiling FINAL F.LECTRI AL INSPECTION_ DRIVEWAY APPR Al --- Final Buildin Survey Next schedule inspection ( call when ready ) Remarks- Building Inspector 5/86 and-vl 6/0 . r _Jown o/ Queerrshurc� r � BUILDING and ZONING DEPARTMENT 1 ay and Hawiland Road, R. D. 1 Box 98 Pf Queensbury, New York 12801 f+ BUILDING INSPECTOR ' S REPORT NAME ,1[� a JJ��� �r J LOCATION -- ! 4 r Date / r / Permit No . ✓ = APPROVED - YES &V�Ooting/Pier Forms Foundation waterproofing Backfill Framing Roofing Siding Masonry Ven er Rough Plumbi g 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 P:LECTRI AL INSPECTION _ DRIVEWAY APPR _ A Final Building Survey Next scheduled inspection (call when ready ) Remarks-- fr'�- + r� !S f � 0 zvop 00 Building 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 R`EOUIRED. TEMP. A D/4TE CITY OR VILLAGE TOWNSHIP [. ./rj �f /rs' COUNTY f%fG9f STREET AND md. OR ROAD AND POLE NO. !/. ,71!'41 POLE N BETWEEN RNIAT TWO CROSS STRFET'S IS PREMISES LOCATED? SECTION BLOCK LOT _ DCCUv^ft BUILDING - - ,, r,�' NAME t= C. / l 7'"t .�+''l'�„� O'=UPANCY (,`=G��,,.r�/7! C"Y OWNER'S NAME ,/� "AND ADDRESS f { �^'E 4L ,?1'�4+�ry� i_7 �+ 7 .? �, . Gs—„ ,tea TEL.L. # '.�• BSUPPLIEp FROM THEIR OFFICE f—I Is NEW r ! � MEW OLD is DEFECTS NEW ADDITIONAL ❑ REMOVED LJ LIST BELOW ALL EQUIPMENT WHICH YOU INSTALLED NUMBER OF OUTLETS No. of FixwNs m BRANCH Loos- Lamp Receptacles MOTORS HEATERS CfRCU1TS OFFICE USE ONLY flat Bide AR*W P. WorseA.W.4. Co..,. Wall Reo4'II Switch Peadant Brucker No. TV" Each No, Eam Na. Gauoe INSPECTION Ovr Bide Satt- bw eom ntaee tot F1. 2nd Pl. 3rd Fl, REMARKS: LIST OTHER ELECTRICAL DEVICES NOT SET FORTH ABOVE; DO NOT USE THIS SPACE, This aPPlieatian is ineen fed to raver the abova-lietad equipment to be impacted but if at time of inspection share is found odditionY are auWorized so make the maps c6on and adjust the fee to cover the additional equi aquipmsnt oof above listed, you pment, as ProridM by the applicant SIZE OF ELECTRIC SIGN TOTAL MAINS FEEDERS LAMPS WATTS CHARACTER EXPOSED GAS TUBE SIGN OF WORK 1C6FICEALED TRANSFORMERS OF VA WORK TO BE INUMSERI ICAPACITY1 STARTED COMPLETED SIZE OF SIGN SERVICE OVERHEAD UNDERGROUND MAKER ENTERS 1L 1 OF SIGN INSPECTION REQUESTED ON OR AS NEAR AS POSSIBLE I NEW El OLD AVOID DELAY BY 41 VI I44 FULL AND ACCURATE IN FOR MATT O N. ALL SPACES DATE OF _ MUST BE FILLED IN OR APPLICATION MAY BE RETURNED. APPLICATION— PRINT NAME_AND AD RESgNAME OFry�' /I APPLIC NT �J �i rJ�'s r �{ _ .�„ 1/ SIGNATURE �y' OF APPLICANTc�-.e'� - "✓Tf fi �l'�;• STREET ADDRESS /-...." u` 7' -1 w� it TELEPXONE CITY OR ZIP LICENSE NO, POST OFFICEl . . .:I � �^t'� .,. J c• • CODE I'..Fr.' WHEN APPLICABLE 40 EL IRFV. Ilan] A SEPARATE APPLJ TION MUST BE FILED FOR EACH SEPARATE BUILDINGS X N o+e- s �(- Unouthorize.d calfiero+iorl or a3di+ion +ca a Sur veL) mop bearing a licensed land zv r uor'; Seca �s a violation o� 5eo�tion 72Oq , subdiv i s« 2 , at the New York 5+cr�e Ed co ion Lnw. . Only copes from the orig5inol 0 e ihi s survey ma marked wi+h can art 1 o� thland s� v soars embossed seal 3hall be coos idered to be vo I id true c-opies. Subjeci to highwa►u) use--dedicQt'ion of re;orc# and cant_) era5ernen-i-s of record. * F)eference. deed -(, C)P,tVy b. Zve-r liS and por ine- �5. bullock, ca Executors o the-,lca,5+ Will ornd Tes'tnrnent� o� Fri s H . Beers +o Oorine. 13. �ulloci'. doted : Mot✓) 31, 198 t reco-rded : .Surma 17, 198i L i ber ca39 , Pgc)e 963 a- . of a st,rvej-3 of a parcel of land prepared -�or �� of NEW r Fra.&rlch L* e� 5&rbara M* Champa na, �PEiO W. • eFZ'�Ir , .• F; * Si-i'uoi-e in the_ Torun o-F Queen,5bury , Coot.) of Warren, S+a+e- of Mew York scale l "= doh : Aux-). 24,1987 5ichoAr—d' W. - benneft r�.vl� : Sep-. S M-7 4cn Shaw 049 �°� V�J��o L i cen 5ed Land 5urZWr r' +h r�� lof 5uhd i vi s ia1 LAND `� Glens Fo11.5 , tJew Mo. 04949 3