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1987-730 44 t � • F C�✓RTIFICA.TE OF OCCUPAN'(O".4.11Y TOWN OF +QUEENSBURY WARREN COUNTY, NEW YORK Date &7UI y 6 !9 88 CW This is to certify that work requested to be done as shown by Permit No. 87-730 has been completed. This structure may be occupied as a One Family Dwelling l.ocarion Lam 44- Pheasant Walk Owner Pro Craft , Inc . By Order Town Board IrO WN OF QUEENSBUR Y Building ar Zonii►g Inspector BUILDING PERMIT TOWN 4F +QUEENSBURY No. $7- 730 � WARREN COUNTY, NEW YORK PERMISSION is hereby granted to Pro-Craft Inc . w OWNER of property located at Lot 48 Pheasant Walk Street, Road or Ave. 00 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. t. OWNER'S Address is 11 Pheasant Walk o Queensbury , N . Y . 12801 Cn m r7 2. CONTRACTOR or BU1 LDER'S Name H Same n 3. CONTRACTOR or BUILDERS Address r 0 4. ARCHITECT'S Name r r 00 CA S. ARCHfTECT'S Address ro m 4a w for G. TYPE of Construction — (Pismo indicate by XI !v I� 1V4 Wood Frame i I Masonry i } Steel f } 7. PLANS and Specifications No. 58 ' x 48 ' per plot plan , specifications add application including Septic system and attached two car garage . q B. Proposed Use ' (D One Family Dwelling B r4 r $5 . 00 CIO ty $ 115 , 00 PERMIT FEE PAID - THISPERMIT EXPIRES May 1 ' 88 19 rEo 0f a longer period is required an application for an extension must be made to the auiIding and Zoning inspector of the town of Clueensbury before the expiration date.} ` Orc! Dated at the Town of Queensbury this 29th Day of October 19 87 /] r SIGNED BY cG{'aLa! "" for the Town of Queensbury Building and Zoning Inspector /G . TOWN OF TO BE COMPLETED BY BLDG . DEFT. / G� Application No . I sL own uQerat y6xtr� Permit Issued 19 OCT 19 1997 BUILDING and ZONING DEPARTMENT Permit Expires 19 Bay and Haviland Road, R. D. 1 Box 98 Zoning Designation ' I'I 1tL` �F'u `�c i_433E 0 Queensbury, New York 12801 Varianc b 20 Site P an Review o . App APPLICATION FOR 9 BUILDING AND ZONING PERMIT t _ . 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 . -----_____________........ ___ _ J-'----------___---________- -- ----------_---_-_ ----- The owner of this property is : 'J [�. 1 !/ /✓r�� P . O. Address /!ram GL/ Z Tel .'790 / 3 33 Property Location : 4� Tax Map No .` / / Street number or building lot number " Subdivision name (if applicable) Z 9S / THE PERSON RESPONSIBLE FOR SUPERVISION OF WORK AS REGARDS BUILDING CODES IS : �✓ !' AJ Name P . O . Address �y Tel . No . Name of builder 1¢/'f Address lam, Tel . ,Q �� Name of plumber / r rr Address Tel . / + Jr Name of mason /r it Address NATURE OF PROPOSED WORK : ZONING INFORMATION : X.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 LOCATION OF STRUCTURES AFFECTED _ of water supply and location and configuration * of septic disposal area . COMPLETE INFORMATION REQUIRED BELOW , Size of property /GHQ - ft X a2 [] C3 ft _ * Existing building ( s) Size ""'" ft _ PROPOSED BUILDING AND USE : Existing building(s) Use Size of new structure =ft X_; f Foundation-pier/slab/crawl/partia /full ' Proposed building, distance from property line (circle one) i Front yards ft Rear yard J / s' f ft No . of stories (habitable space ) /� * Side yards �1 ._ ft and — r r ft Height ( grade to ridge )If residential , no . of families * If on corner , setback from side street �' "" ft J No . of rooms ( excluding baths ) �+� OCCUPANCY INFORMATION No. of bedrooms No , of bathrooms * PRIMARY BUILDING - Primary heating system C C_ e G * One family dwelling Type of fuel * Two family dwelling No . of fireplaces to be installed_ . * Multiple dwelling / Number of units Will a wood stove be installed? _A1,0_ * Permanent occupancy Central Air conditioning? ^11 0 * Transient occupancy * Business BUILDING STYLE, PRIMARY STRUCTURE * industrial Ranch Contemporary Log cabin * Other ed ranch Mansion Duplex If addition , what will use be? 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 two ca �� -�-car * * * * * * * * * * * * * * * * - Private storage buildingg�--�--- ESTIMATED MARKET VALUE OF * Other CONSTRUCTION $ �_ 6c oo�. - - - - - _ — _ INFORMATION ON BUILDING `SPECIFICATIONS , ON REVERSE SIDE OF THIS SHEET, TO BE COMPLETED ! Farm BPA 4/86 and-vl BUILDING PERMIT APPLICATION CONTINUED BUILDING SPECIFICATIONS : Type of construction , woodd fr�ame�fire safe , etc . Will any second-hand or ungraded lumber be used? If so , for what? Foundation wall material /�dy � y� A? �� .vim Thickness Depth of foundation below grade (to bottom of footing ) ,N6 Will there be a cellar? jo, Heated or unheated? L/ Floor sq. footage /C,GZ i sq ft Will there be a Iraascmen ? k- will any portion be used as living space ? �/G ( If so , what portion? sq . ft . - - Type of use? Type of roof - ope flat/shed/other -��- ///// Material of roof S r.tf,✓ c� G Size , wood studs_ + X__C spacing"o . c . length eft . Joists ( floor beams) 1st . floor "_'X -" spacing ,/6"o . c . span ..L.Z� ft . Joists ( floor beams) 2nd . floor � --- spacing "o . c . span ft. Overlays ( celling beams ) - " spacing "o . c . span £t . Roof rafters spacing o . c . span ft . Roof trusses (pre-engineered) spacing ..Z�L_"o . c . span,,?NNL�_ft . Exterior wall finish �4j~1 Z2 iAJG of what material ? Interior wall finish If garage is to be attached , describe materials to be used for FIRE SEPARATION : $ /%�/ e c S.A 7 o G ►c Is there to be an opening between garage and dwelling? 2f so will a Fire-rated door , enclosure , and self-closing device be provided? Will a flue-lined chimney be installed? 1!�� Height above roof z ft . Depth of chimney foundation below grade ft . ,& Depth of fireplace hearth 7. f ft . in . Water supply - unicipa or private well SEPTIC SYSTEM _ Distance from ANY private well ( including adjoining properties ft . (A separate application is necessary for any repair or new installation of septic system) Town of A F F I D A V I T STATE OF NEW YORK eensbury Warren 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____ _ _ cc� Owner , 019m ' Is , rcnitect . ntractcar �S day of �= T 19 7 Notary Public , Warren County , N . Y . SPECIAL CONDITIONS OF THE PERMIT : BY 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 : 1-7 1 . Gross floor area 7 2 , Type of heat 3 , Is the building mechanically cooled ? 00s" / 4 _ f . 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 10 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 54 Type of insulation B , Under 16 % Only 1 , R value of roof and floors exposed to ambient conditions. 2 , R value of exterior walls if r� S �� 3 . R value of glazed area 4 . R value of doors .rac" — 5' 5 . R value of floors over unheated spaces 6 . R value of slab edge insulation - unheated slab 7 , R value of slab insulation - heated slab r Be R value of heated basement/ cellar walls ( above grade ) 9 , R value of heated basement/cellar walls ( below grade ) 10 , Type of insulation- } e�° ,Lr .gs" /2 C . Controls PG7 1 . Thermostat maximum heat setting 75 p . 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 �T E . Piping hot w 1 . Sizea o of f hot water or cooling carrying agent pipe_ 2 . R value of pipe insulation_ r F , Service Water Heating 1 , Performance efficiency _ ra Woo 2 . Temperature control setting maximum G , For Swimming Pool Only 10 Maximum heating__ "T Telephone No . ( appl ' cant sig atur %wYoarft Of APPLICATION FOR SEPTIC DISPOSAL PERMIT BATE LOCATION OF PROPERTY FOR INSTALLATION Z,,, :4 Owner's Name: 7� jIf- Telephone: Address: _f / ,/fC �7 5�} LCl� ee.) Installer's Name: /P rid /�,��7- ,/j&/cf," Telephone: ,25 Number of bedrooms (residential only) _ �:3 _ Total daily flow (compute @ 150 gal per bedroom) Topograpby: circle one: at Rolling Steep Slope % of slope Soil Nature: circle one: and Loam Clay Other / Depth: feet Ground 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- Municipa Well Other IF domestic water supply is a Well: _ Separation: Watersupply from Septic absorption _ feet PROPOSED SYSTEM : Septic Tank gal. (minimum size: 1 ,000 gal.) TILE FIELD: Each Trench 41e%' feet / Total system length IA-Y y feet SEEPAGE PIT(S) : Number of "~7- Size each -- feet by — feet Size of stone to be used. # �• i_ / Depth or Thickness feet IMPORTANT ...Please...IAST NEW EQUIPMENT TO BE INSTALLED (over) Section II Septic System Ins ections: A. All applications for septic system installation, alteration or repair, as required by the 'Town of Queensbary 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 So) 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. Co 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. l have read the regulations above and agree to abide by these and all requirements of the Town of Queensbury Sanitary Sewage Mspwsal C)rdinance. Signature of responsible person: / Date: Town of Queensbury Building and Code Department Bay at Ilaviland Road Queensbury, New York 12801 (518) 792-5832 SETTLED 1763 . . . HOME OF NATURAL BEAUTY . . . A GOOD PLACE TO LIVE 40573 $ 1 THE NEW YORK BOARD OF FIRE UNDERWRITERS BUREAU OF ELECTRICITY 7.tBl 41 STATE STREET, ALBANY, NEW YORK 12207 L7ul.pa21 r 1988 Application Al on file 133 90 8 / 87 f ? ?CERTIFIES GETIFfES THAT V only the electrical equipment as described bestow aFud introduced by the applicant nomad on the above application number in the premises of Pro Craft Bulldera Lot # 48 Pheasnat Walk Glens Falls , New 'York in thefollowing location; 1:j Basement El lat F'l. ❑ Rnd Ft, outside Section. Black lot # 4 8 was examined an 7-- 11—8 8 and found to be in compliance .pith the requirements of this Board. IIXTURR FIXTURES RANGES COCKING PECKS OVENS I DISH WASHERS EXHAUST FANS OUTLET€ RPTACLES SWITCHES 1 AMMSCEN1 I FLLKXWSCENT AMT. N. W. AMT. K- W. AMT. K.W. AMT. X. W. AMT. H. ►- 16 33 1 18 ? f r DRYERS FURNACE MOTORS FUTURE "MAWS FIEDERS ISIPMAL 1111CIPTI TIME CLOCKS I matt I Ll BEATERS I MULT"WTIET DIMMERS AMT, K. W. Cs. H. P. GAS H. P. t AMT. %10- A. W. G. AMT. AMP- AMT. AMPS. I TRANS. AMT. H. P_ NO. SET AMT. WATTS F � 0 1 f) 1 SERVICE DISCONNECT NO. OF S E R V I C E AMT. AMP. TYPE METER 1 ,,e' 2W 1 X 3W 13 X 3'wv 3 X lW NO. F Rw CC. OF CC. C4ND. ND. W IM LLEG - IEC. NO. OF NeurtArs OFA. NEU RA. 1 200 cb 1 x 4 / 0 2 / 0 OTHER A►FARATM Elec . Room Heaters * 3 / 2 . Or 4 / le75r 2 / 1451 111 . 75 _ 3-gfci 1 -- smokie detector Era Electric Co . � RD # 4 339F . Candleber.ry Drive rii; Falls ♦ NY 12801 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'lrteir credentials. COPY FOR BUILDING DEPARTMENT. THIS COPY OF CERTIFICATE MUST NOT BE ALTERED IN ANY MANNER. Jo w re cru c+e n 3 6 eery BUILDING and ZONING DEPARTMENT Bay and Haviland Road. R. D. i Box 98 • Oueensbury, New York 12801 BUILDING INSPECTOR ' S REPORT NAME _ LQCATIC7N eAO yC _�7`4 Dates PermitZ No . ✓ - - Footing/Pier Forrns APPROVED YES NO Foundation Waterproofing Backfill Framing Roofing Siding Masonry Vene r --- -- Rough Plumbi Relief Valves - Ext . porches Finished Flop- rs — ^ Interior Trim Stairs & Railing Cellar Drain Tii Concrete Floors PIbq , Fixtures Gar . Fireproo ing Door Closers :;mc3ke Detect rs Chimney INSULATION ; Foundation Floors Walls_ Ceiling FINAL ELEC RICAL INSPECTIO DRIVEWAY AP P VAL Final Building Survey* Next scheduled inspection { call when ready} Remarks- je4X�r4 &f SjA1Y. A.tn-Cv 13u ' ding in ecto 6/86 Md-V1 1 014 fjOwIt D/ Qll � E'/r3pZL/"d� ✓ BUILDING and ZONING DEPARTMENT Bay and Haviland Road, R.D. 1 Box 98 Queensbury, New York 12801 BUILDING INSPECTOR ' S S REPORT NAME �/ '.% /ljz. LOGAT I C7N _ ,r p © ,r r / Dates _ tl / r� P!!er/rnit Ncy . 7` ![�'. 4 d* tz Yr = - YES Footing/Pier Farms APPROVED NO Foundation Waterproofing Backfill Framing Roofing Siding MasonrV r Rough g Relief Ext . P Finish InteriStairsngCellarileConcres Plbg . Fixtures Gar . Fireproof! g Door Closers Smoke Detector Chimney SUI,ATTON : Foundation Floors Walls CezlingLiz FINAL ELECTR AL INSPECTION DRIVEWAY APPR VAL_ Final Building Survey Next scheduled inspection ( call when) ready ) Remarks- klding YnSpector 6/86 and-vl �OW/i !J� �L4"¢IP1Y3 �LlI"t� BUILDING and ZONING DEPARTMENT Bay and Haviland Road, R.D. 1 Sox 98 Queensbury, New York 12801 BUILDING INSPECTOR 'S REPORT NAME LOCATION Date 3 3a Permit No . ✓ = - YES NC7 Footing/Pier Forms APPROVED Foundation Waterproofing Backfill Framing Roofing Siding Masonry Ve eer Rough Plum ' ng — "- Relief Val' Ext . Porches -— . Finished Flop Interior Trim Stairs & Railin Cellar Drain Til Concrete Floors Plhg . Fixtures Gar . Fireproofing D00Y Closers_ Smoke Detectors Chimney INSULATION : Foundation Floors Walls Ceiling FINAL EL RICAL INSPECTION DRIVEWAY PROVAI.,-____^___� Final Bui ding Survey Next scheduled inspection ( call when ready) Remarks- 4dingJ�ctor 6/E36 and-vl .70tvn n/ Queen36ury BUILDING and ZONING DEPARTMENT Bay and Haviland Road, R.D_ 1 Box 98 Oueensbury, New York 12801 BUILDING INSPECTOR ' S REPORT NAME ffi92 L0CATION Date/ Permit No . ✓ = APPROVED - YES NO Footing/Flex Forms Foundation Waterproofing Sackfi. 11 )'Framing Roofing NL Siding Masonry Veneer /( Rough Plumbing Relief Valves Ext . Porches Finished Floors Interior Trim Stairs & Railings Cellar Drain Tile Concrete Floors Plbg . Fixtures Gar . Fireproofi Doerr Closers Smoke Deteoto chimney INSUTAATION Foundation Floors Walls Ceiling FINAL E cTRICAL INSPECTION DRIVEWAY APPROVAL Final B iding Survey Next scheduled inspection (call when ready Remarks- bI Sb� GMy►[ �J r \fit re W cam\ Buildin Inspe err 5/86 and-vl f6 c-� f7aevn ©/ Quee" JI " ry BUILDING and ZONING DEPARTMENT ay and Haviland Road. R. D. 1 Box 98 Queensbury, New York 128()1 EPTIC DISPOSAL SYSTEM INSPECTION E LOCAT I CAN_ _ G'lG } _ �'rGL/.2. • DATE // 1411 (5 ;7 PERMIT NO. eq SOIL TYPE - Sand - Loam - Clay - Percolation Test Required ? YES NO Percolation rate - Min/inch TYPE of SYSTEM: TYPE tion field , total len the Length of each trench Z� Depth f trenches Size of gravel SEEPAGE ITS{Number of) Size- £t. X _ ft Gravel si PIPING : Size Type Type Bldg . to tan Tank to disc_ box Dist . box to f eld Openings sealed ES NO Partial LOCATION/SEPARAT s Foundation to t k J�'�+=ft. Foundation to so Lion 2- 3 ft . Absorption to of 13. a 10 ft. Separation of pits ft , LOCATION STEM ON ROPERTY (circle one ) Front - ear Left a! e - Right side - CC7MMENT ey SYSTEM USE APPROVED ES NO ji Bui 3ng tnspector 01/86 and vl Jowr� o ueerz3hur 11BUILDING an C}�G DEPARTMENT Qi Bay and Haviland Road, R. D. 1 Box 98 OF Oueensbury, New York 12801 BUILDING INSPECTOR ' S REPORT NAME 15r� r �'f✓ LOCATION rJ f Date_,!/ _� / _z Permit No . ✓ = APPROVED - YES NO Footing/Pier Forms Foundation W}terproofing tackfiII Framing Roofing Siding Masonry Veneer Rough Plumbing Relie £ Valves Ext . Porches. Finished Floors Interior Trim Stairs & Railings Cellar Drain Tile Concrete Floors Plbg . Fixtures Gar . Fireproo£ in Door Closers Smoke Detectors Chimney INSUL'ATZ ON Foundation Floors walls Ceiling FINAL ELECTRICAL INSPECTTON DRIVEWAY APPROVkL, Final Building Survey Next scheduled inspection (call when ready ) Remarks- �/e/ Building nspector 6/86 and -vl (�/�� �.Joit+n o� �uQens6rertaf BUILD NG and ZONING DEPARTMENT Bay and Haviland Road, R.O. 1 Box 88 v1 pueensbury. New York 12801 ILDING INSPECTOR ' S REPORT AME LOCATION mate (�' Permit No . NO APPROVED - �ting/Pier FoXVLs Foundation Waterproofing Backfill Framing Roofing Siding Masonry Vene r Baugh Plumbin Relief Valves Ext . Porches Finished Floors Interior Trim Stairs & Rani s Cellar Drain T le Concrete Floo s Plbg _ Fixtur s Gar . Firepr o£ing Door Close s smoke Det ctors Chimney IN SUTAATI NS : Foundation Floors Walls Ceiling FINAL ELECTRICAL INSPECTION _......._ DRIVEWAY APPROVA► Final Building Survey T Next scheduled inspection (call when ready ) Remarks- �j � -1 r SuiI r1ing ns Dec 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 REQUIRED. TEMP_ a DATE f f, CITY OR VILLAGE ]�:• • /� ., y TOWNSHIP f -1 r+ .� u STREET AND NO. OR' yj w,-` ROAD AND POLE NO. F- r �' - /"� ( / [f%F"+ t',., IC POLE NO, BETWEEN VO4AT TfMO �r CROSS STREETS IS : ... �r : , /`' (- o PREM ISES LOCATEDt 1 '` tJ / '�,l',c, Jam. +. :J -�.' f �. �r,i�" / gER;TIGW � BLOCK _ 1` LOT eV :. NAME ANT'S ;jjfi BUILDING ~, OCCUPANCY Af ;41 _ OWNER'S NAME f AND ADDRESS F '' - C 1 ' /"A !� ,� �" T'EL_ ibE '' ?'J(. „>• '' CURRENTQ /f,,lr i/ y1rJ FROM THEIR (^:� Mir OFFICE BY II^^;;77 11--YY I-1' FECTS IBtI1LDING NEW L2x OLD IJ IVYORK NEW L3( ADDITIONAL 0 REMO'IfED ❑ -- -- LIST BELOW ALL EQUIPMENT WHICH YOU INSTALLED Nm of Fftimarem BRANCH NUMBER OF OUTLETS LLrmp Roomptatlee MOTORS HEATERS CIRCUITS OFFICE USE Laa ONLY Side Attaeh't HJ_ "am A.W. CeMIn� Well Rovw'ls Bwnitoh Rrrsdwt Bndnt Na Type Each Na Eeeh Na INSPECTION OuI- si/Y Salb- base Bwr we 1st FI- 2nd FI 8sd fl. REMARKS: LIST OTHER ELECTRICAL DEVICES NOT SET FORTH ABOVE: 00 NOT USE THIS SPACE. This application rs interMed to Corer the sba listd owip[nent to be impacted but if n thole of inspaCtioer there is fo&&nd a4 n vi equipment not ebore listed, you are authesieed to make the iresllection and adirut the fee to corer the additional 01*1" e . s provided bV the appGeent.. SIZE OF ELECTR IC SIGN TOTAL MAINS C-? i�:�!'.: /� I' FEEDERS t..AMPS WATTS CHARACTER EXPOSED GAS TUBE SIGN OF WORK CONCEALED TRA NSFOIIIN E RS OF VA WORK TO BE INUMBERi ICAPACITYI STARTED COMPLETED SIZE OF SIGN SERVICE OVERHEAD UNDERGROUND MAKER ENTERS OF SIGN IL ING INSPECTION REGUESTEO ON OR AS NEAR AS POSSIBLE NEW OLD AVOID DELAY BY GIVING FULL AND ACCURATE INFORMATION, ALL SPACES DATE OF MUST BE FILLED IN OR APPLICATION MAY BE RETURNED. AP PRINT NAME "D ADDRESS r \/ SIGNATURE NAME OF /., _. � t r1l f`_. A APPLICANT_ / J dy�`' I- OF APPLICANT*-,� a-- r f STREET ADDRESS f Jr'r�• ;' >�-� :U _ 1-.1�/�f CITY Oft /-.. _- r ZIP LIC NCO. POST OFFICE ! - / i' i - `rf 1 r ...[{........�/ CODE k�G� I 1NHEN APPLICABLE 4e EL (ff"- ile0) A SEPARATE APPLICATION MUST BE FILED FOR EACH SEPARATE BUILDING I ulgo., ........... ....... ENE REM- InN N?NSWTMR� 'MQ�,'"'M sg' n2ft-t!�—It ==-T Qj T,�" 00 '041 M 1 2�7 g,� 1W %SWAT, =_5_W.�M7=Tz% �MF OW '.i., k, VS 5 MEW, My MOM!, 11 ol WIM FIND _7M A �iw - ---- gvi _o_ mt