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1987-715 t T ♦ CERTIFICATE OF OCC PAN CY TOWN OF QUEENSSURY WARREN COUNTY, NEW PORK Date January 15 , 19 87-7 15 This is to certify that work requested to be done as shown by Permit No. has been completed. One Family Dwelling This structure may occupied as a •�+a r Willow Rd . The Pines of Queensbury Location Joe Koulier Owner By Order Town Board TOWN OF QUEENSBURY Building & Zoning inspector BUILDING PERMIT � TOWN OF QUEENSBURY No. 87_ 715 o WARREN COUNTY, NEW YORK 0 I PERMISSION is hereby granted to Joe Roulier p° OWNER of property located at Lot ##41 Willow Rd (The Pines of Queens Street, Road or Ave_ Bury) in the Town of Queensbury, To Construct or place a One Family Bwelline 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. 6 f . OWNER'S Address is Box 301 Cleverdale , N . Y . o G l-" (D m ►s 2. CONTRACTOR or BUI LDE R'S Name Same 3. CONTRACTOR or BUILDER'S Address H t— G` O ro rr 4, ARCHITECT'S Name rtiy F-w F- f0 f•� O H S. ARCHITECT"S Address t" p ro � to p. G Ga Fi- TYPE of Construction — (Please indicate by X) G M ( )f Wood Frame I I Masonry I I Steel i 1 7. PLANS and Specifications No 681 x 24 ' per plot plan , spe dfications and application including o septic system, attached two car garage and driveway permit S. Proposed Use One Family Dwelling $5 . 00 C /(] May 1 , tg 88 $ 143 . 00 PERMIT FEE PAID -- TEAS PERMIT EXPIRES G (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 26th bay of October 19 87 SIGNED BYc� + �` for the Town of Queensbury Building and Zoning Inspe or -f TO BE COMPLETED BY BLDG . DEPT . c� Application No . Down o�' ueeres6sere� Permit Issued 19 BUILDING and ZONING DEPARTMENT Permit Expires l9 (3,Ni Bay and Haviland Road, R. D, 1 Box 9$ Zoning Designation Queensbury, New York 12801 Variance No . � � L Site Plan Review No . �r,-T 15 51987 `-f � Approve by ,L APPLICATION FOR i / 3� FUILDING AND ZONING PERMIT l >F aE LA ]] 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 Per The owner of this property is : mit . �- �----- --- -------- _ ,30 �r P . O . Address . +'%ore Property Location : -f'•� 'C��ww .+a �7� / Tax Map Street number or building to number Subdivision name (if applicable) THE PERS RESPONSIBLE FOR SUPERVISION OF WORK AS REGA MS BUILDING CODES IS : Name // P . O. Address Tel . No . Name of builder ,. rwG. ►' Address '� " Tel . Name of plumb Address �� .l t .__Tel . ?Sr y - a 'C rr3 -` .. el . � Name of mason .■■ +�� Address +. NATAE OF PROPOSED WDRK : 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_ /„3o ft X / Jn ft . * Existing buildings ) Size�_ft X ft . * PROPOSED BUILDING AND USE * Existing building s ) Use Size of new structure .�ft Foundation-pier/ slab/crawl/partial �' Proposed building , distance from property line * ( circle one ) Front yard � O ft Rear yard ft No . of stories (habitable space) • * Side yards wv 31 ft and nr ft Height ( grade to ridge ) _ � A yf _ ft . * If on corner , setback from side street ft If residential , no . of families / OCCUPANCY INFORMATION Now of rooms ( excluding baths ) ,_ * No . of bedrooms_ * PRlpz<ip'Y BUILDING No . of bathrooms �► ' * One family dwelling Primary heating system ("„3�0 + * Two family dwelling Type of fuel 6w s Multiple dwelling / Number of units Now of fireplaces to be .installed * Permanent occupancy will a wood stove be installed? •✓+ Transient occupancy * Central Air condltioning?y r * Business BUILDING STYLE, PRIMARY STRUCTURE industrial �, Other Ranch Contemporary Lag cabin * If addition , what will use be? Raised ranch Mansion Duplex Split level Old style Bungalow * ACCESSORY BUILDING- Ca e Cottage Other car Town House * Detached garage/one car/ two olonial Row Cal - CIRCLE CIRCLE ONE PLEASE ) * Attached garage/one c t o ca 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 APPLTCATIDN CONTINUED - BUILDING SPECIFICATIONS : Type of construction wood frame fire safe , etc . Will any second-hand or graded lumber ,b�.e/used? If so , for what? Foundation wall material �.�w.r4ra i /- + a _ � Thickness ./ o `• Depth of foundation below grade (to bottom of footing ) w.. .. Will there be a cellar? ee -Heated or unheated? Floor sq. footage .,, ff. �-�sq ft Will there be a basement? Will any portion be used as living space? { If so , what porn 0 sq . ft . - - Type of use? - Type of roof - slo ed lat/shed/other Material of roof Size , wood studs "X " s acin ", � 4.: p g'�__- o , c . length __A!Lft . Joists ( floor beams ) lst . floor :.4_"X / !3 Is spacing��"o . c . span �„ ft . Joists ( floor beams ) 2nd . floor V "X ,ra IF spacing �.�C '• /, o . c . span ft . Ovc�rlays (ceiling beams ) "x " spacing "o . c . span £t . Roof rafters "` "x spacing o . c . span ft . Roof trusses (pre-engi eered) st>acing " o . c . spank/ -ft . Exterior wall. finish ..,o Of what material ? ,r��w ' Interior wall finish � ,� '� �� r ' For If a garage is o be attacl3pd , describe materials to be used for FIRE SEPARATION : jW < • I/�r6 Is there to be an opening between garage and dwelling? If so will a Fire.-rated door , enclosure , and self-closing device b6t provided? a.! Will a flue-lined chimney be installed? Height above roof ft . Depth of chimney foundation below grade a. Try ft - Depth of fireplace hearth CV . te;p in . Water supply - Municipal or private well 6 ., a ,aeQr (" SEPTIC SYSTEM _ Distance from ANY private well ( includzng adjoining properties r✓ * ft . (A separate application is necessary for any repair or new installation of septic system) Town of Queensbury p ►1 1r County of Warren ►-1 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 Signatur�_ __-------_-J �_ Ison ooe -- � Owner , owner ' s a _ t , arcnxrect , contractor r''es day of C.�'�~ 19 dr'' a/ Notary Public , Warren County , N . Y . * * * * * * * * * _ * * * * * * * * * * * * * * * * * * * * * * * * * * IF 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 : 1 . Gross floor area /7 ' 'Powwo � 2 . Type of heat 3 , is the }wilding mechanically cooled ? 04 40- -- 4 . Percentage of area of windows and doors A . over 16 % Only 10 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 YESr what is the R value of insulation around perimeter of floor ? 4 , Is basement heated ? YES NO a . R value of insulation 50 Type of insulation B , Under 16 % Only 1 , R value of rao and floors exposed to ambient conditions_ 3 Vp 2 . R value of exterior walls ,J` 400 3 . R value of glazed area 4 . R value of doors 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 80 R value of heated basement/ cellar walls ( above grade ) �.� 9 . R value of heated basement / cellar walls ( below grade ) 10 , Type of insulation . 4'� ss ►r n C . Controls 10 Thermostat maximum heat setting Do Duct Systems 1 . Is duct system installed in unheated spaces ? YES NO a . If YESr 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 am 2 . Temperature control setting maxl'urfAm — G . For Swimming Pool Only 1 . Maximum heating Telephone Now Vw Va 4i �rC 1 '3 ' V ( appli. can ' s signature ) ,aw lrftl'n dfaeaw&arp APPIACA77ON FOR SEPTIC DISPOSAL PERMIT DATE _r r LOCATION OF PROPERTY FOR INSTA ELATION ,� Owner's Name: +[ "or / Telephone: .s%/�^ CSC -3s ^f�'Y` Address:— �3 4' Gc ..e.q'r. is .+1.! f Installer's Name* 4 w Telephones Number of bedrooms (residential only) Total daily flow (compute @ 150 gal per bedroom) y'r Topography: circle one Fl Rolling Steep Slope % of slope Soil Nature: circle on San Loam Clay Other / Depth. feet Ground Water: At what depth? PO—Lfeet Bedrock or Impervious Material: At what depth? _ v q feet Percolation test: circle one: not re�q-u'i�r'ed required / rate �' min. inch. Domestic water . supply: circle one, Municipal Well Other IF domestic water supply is aWelell.: Separation: Watersupply from Septic absorption i feet PROPOSED SYSTEM : Septic Tank /� gal. (minimum size: 1 ,000 ,gal.) TILE FIELD: Each Trench � S+ eo feet / Total system length cheawu� feet SEEPAGE PIT(S) : Number of fir-- / Size each feet by feet Size of stone to be used # / Depth or Thickness .=N _ feet IMPORTANT ...Please...LIST NEW EQU PMENT 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 $250.00, C. An approved copy of the plot plan shall be available on the construction site. Failure to produce said plot plan at time of inspection may result in an immediate work stoppage. D. Should unforeseen problems during construction prevent proper installation, alteration or repair of an approved system , a new proposal must be submitted to the Queensbury Building Department before further construction. l have read the regulations above and agree to abide by these and all requirements of the Town of Queensbury Sanitary 'Sewage Disposal Ckxtianance. Signature of//responsible person; Date; r �� W/ ---- r Town of Queensbury Building and Code Department Bay at Haviland Road Queensbury, New fork 1Z801 (518) 792-5832 SETTLED 1763 . . HOME OF NATURAL BEAUTY . . A GOOD PLACE TO LSVE THE NEW Y+ORK BOARD OF FIRE UNDERWRITERS F— ta , BUREAU OF ELECTRICITY May 24 , r 198E 41 .STATE STREET. ALBANY. NEW YORK 12207 Date Application .Vo. "r file 0 2 9 5 I 0 // 8 7 A 7 .�{i ^7 *1 7 3 THIS CERTIFIES THAT 1 only the electrical equipment an described belapm and lea4 b ha eplrl mad the al we gpplicatia.s rsr4mbar in the pramieea of E3aralier Ccsnst . CL� . Lot 4 W]�ow ens at9rrS S . ` c w or Ar%F outside # 41 in the following location; Basement 1st Fl. [J 2nd Ft, Section Block Lot too& examined on 1 1 3 — 8 8 and found to be in compliance u+ith the requirements of this Board. FIXTURE FIXTURES RANGES CQOICLNGL lxcKs Q VENS DISK WASIiERS EXHAUST FANS 04JTL.ETS ACILS SWITCHES IMJCANDESCEM FLUDICESCEM yA AMT. K. W. AMT. K. W. AMT. K.W. MAT. K. W. AMT. N. P. 23 63 16 3 fr DRYERS FURNACE AIGTCIItS FUTURE APPLIANCE FEELIERS ISMCIALR#CPT VhU CLACKS WU I 6NMT NEATER$ MULn-ounm Dupjohm AMT, K. W, 0IL H. P. GAS H. P. 040. . G. AMT. AMP. AMT, AMPS. TRANS. Mt#. H, P. NO Cw�T AAkT. WAT#B SERVICE DfSCIUNNECT N6. tSF S E It i C E AM#. AMP. Ty" 1 t' 1'1M # .e awv 3 / rw 3 0 4W no. OFCC. CONDPlot AT . OF C ,C. 0..co"D. Na. OF HI.LEG �'H'L� Na. OF NEUTKA s A. W. G. L 1 2Q © cb 1 x OTHER APPARATUS: Ejec P Room 'Heatters e 3 2 . f: , r , 2 -gfci 1 - smoke detector Bra Flectric Co . ti .. -.. RD #r 4 339F Candleberry Doc Lve Glens Falls , NY 22801 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. I _ locuri oueen she< rr� BUILDING and ZONING IDEPARTMENT { � Bay Q eensbu y. N w YOrkD12801 98 BUILDING INSPECTOR ' S REPORT NAME ,r,. rs LOCAT ION Zip 09 Permit No . C7 z —ram/ Date APPROVED - YES NO footing/Pier Forms Foundation waterproofing 13ack f IML 11 framing Roof ing Siding Masonry Ve er Rough plumbi g KRelief Valves >(Ext . Parches )C finished Floors X'Intezior Trim stairs & Railings Cellar Drain Tile concrete Floors VI'} h,3 . Fixtures ''Gar . Fireproofing YDoor closers VSmoke Detectors chimney IN SU L.AT I ON Foundation Floors Walls, Ceiling FINAL El 'ECTRICAL IN SPECTION DRIVEWAY APPROVAL e`y XFinal Building Sury Next scheduled insP ection (Call when ready ) Remarks- 0 , 45, Ru n Inspector 6/86 Ind-VI BUILDING and ZONING DEPARTMENT Bay and Haviland Road, R.D. 1 Sox 98 Oueensbury, New York 12801 SEPTIC DI5 SAL SYSTEM INSPECTION NAME LOCAT IC1LJ, r/ r DATE ' 2 14:4 f7 PERMIT NO . SOIL TYPE - Sand - Loam - {Clay - Percolation Test Required? YES - NO percolation rate. - Min/Inch TYPE of SYSTEM: iv Absorption field , total le th L Length of each trench r Depth of tree }yes ' Size of grave — - SEEPAGE FITS{N er of} Size- ft. _ f t. Gravel size PIPING : Siz ,ITyEe Bldg . to tank +' Tank to list. bo Dist. box to fiel p Openings sealed? S O Partial LOCATION/SEPARATIONS I f t. Foundation to tankf t . Foundation to abso ti Absorption to lot ine Separation of pi ft. ION OF SYS ON PROP TY (circle one) rant - Rear - ft Side - ght side TS : SYSTEM USE APPROVE ES NO Buildi Inspector 01/86 and v1 .._../overt a� �uPen3hur� i 13L)ILQING and ZONING C)EPAF4TMENT Bay and Haviland Road, R, D. 1 Sox 98 Clueensbury. New York 12801 BUILDING rINSPECTOR ' S REPORT NAME LOCATION Perm it Date II APPROVED* -* * S* NO Footing/Pier Forms Foundation waterproofing Esackfill �'aming Roof ing Siding Masonry Veneer Rough Plumbing Relief Valves Ext . Porches Finished Floors Interior 'Prim Stairs & Railings Cellar Drain Tile Concrete Floors Plbg , Fixtures Gar . Fireproofin Door Closers Smoke Detectors Chimney IN SU LAT I ON Foundation Floors walls Ceiling FINAL ELECT AL INSPECTION _ I)RIVEWAY APPR V L Final Building Survey ction ( call when ready ) Next scheduled inspe Remarks-- Hui ing Inspector 6/886 Md-vl i Queen3Iury own o� i BUILDING and ZONING DEPARTMENT Bay acid liaviland Road, R- D. I Sox 98 r � ueensbury. New York 12801 lei ✓�,'aFi BUILDING INSPECTOR ' S REPORT NAME LOCATION t"t 4 , / G i Date %� / Permit No APPROVED YES NO # Footing/Pier Forms Foundation waterproofing Back£ ill Framing Roofing Siding Masonry Vene G- c5ug'h Plumbin Relief Valves Ext . Porches Finished Floors Interior Trim Stairs & Railing Cellar Drain Ti e� Concrete Floor Plbg . Fixtur Gar . Firepr fing Door Close Smoke Det ctors Chimney INSULAT N - Foundat on Floors walls Ceilin FINAL ELECTRICAL INSPECTION DRIVEWAY APPROVAL Final 'Building Survey Next scheduled inspection ( call when ready ) Remarks- Building nspector 6/8�i and-vl a"/" 01 Quee" 31" ry BUILDING and ZONING DEPARTMENT Say and Haviland Road, R.O. 1 Box 98 Queensbury, New York 12801 BUILDING INSPECTOR ' S REPORT NAME + LOCATIO Z6 / /! ZJ � 106 N 12—C;2 Date _/ r Permit APPROVED - YE. NO Footing/Pier Forms Foundation Waterproofing Backfill Fraining -• Roofing Siding Masonry Ve r ,tR2.uqtx Plumbi Relief Valves Ext , Porches Finished Floors Interior Trim Stairs & Railings Cellar Drain Tile Concrete Floors Plbg . Fixtures Gar . Fireproofi g Door Closers Smoke Detecto s Chimney INSULATION : Foundation Floors Walls Ceiling FINAL ELEC RICAL INSPECTION_ DRIVEWAY A PROVAL Final Building Survey Next scheduled inspection ( call when ready ) Remarks- /lam � owl LIZ. Building Inspector 6/86 and-vl F3UILD�NCaa d QG QEP TNINT /`� Bay and Haviland Road, R. D. 1 Box 98 Queensbury, New York 128ol BUILDING INSPECTOR ' S REPORT NAME LOCAT ONy , ,' ��,r Date r/,r f � Permit No . P'/` v ✓ APPROVED - yS NO Foating/Pier Forms �,..� Foundation Waterproofing Backfill Framing r' 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 F.LECTR AL INSPECTION DRIVEWAY APP OVAL Final Builds ,g Survey Next scheduled inspection (call when ready ) Remarks- Buildi Inspector 6/86 and-vl s II awn n/ ueensbure�I BUILDING and ZONING DEPARTMENT Bay and Haviiand Road , R.D. 1 Box 98 Queensbury, New York 12801 BUILDING NSPE OR ' S REPORT NAME ,s /y At LOCATION Date Permit Now ✓ = APPROVED - YES NO Footing/Pier Forms Foundation 1/<� / aterproofing X Sackfill raming Roofing Siding Masonry Veneer — Rough Plumbing Relief Valves Ext , Porches Finished Floors Interior 'Trim Stairs r 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- Building nspector 6/86 and-vl BUILDING and ZONING DEPARTMENT 'f Bay and Havifand Road, R. D. I Box 98 Queensbury, New York 12801 I LDING INSPECTOR ' S REPORT AMEr LOCATION . C � c 2/ f Date /fJ / _ permit No . ✓ = - C..-r'ootingfPier Forms APPROVED YE NO Foundation Waterproofing Back£ill Framing Roofing Siding Masonry Venee Rough Plumbin Relief Values 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 ELECT CAL INSPECTION DRIVEWAY APPROVA Final Building Survey Next scheduled inspection ( call when ready ) Remarks- U44 Buildi Inspector 6J86 and-vl BUILDING DEFT. COPY OF APPLICATION FORM 46-EL, NEW YORK.BOARD OF FIRE UNDERWRITERS. FILE THIS COPY WITH BUILDING DEPT. WHEN REQUIRED, TEMR aF DATE 4ITY CIR ft VILLAGE f R TOWNSHIP COUNTY ; STREET AND ND, on _ ROAD AND POLE NO, -..- -+'/'� - {` pl riff. STREETS ISWO .._. ,^ POLE N . PREMISES LOCATE II OCCUPANT"& ECTION BL K LOT f NAME Y/' OWNER'S NAME OCCUP/iMCV .. AND ADDRESS `"r . SUPPLIED BY BUILDING FROM THEIR OFFICE IS NEW OLO WORK DEFECTS --I IS NEW Q ADDITIONAL ❑ REMOVED E� LIST BELOW ALL EQUIPMENT WHICH YOU INSTALLED NUMBER OF OUTLETS Nam' of Fine A ocar,Ltip" LA Repspbr.{Ir MOTORSHEATERS BRANCH CIRCUITS OFFICE USE CeIIiIq Side I meow-as ot Saalsell Pandmt Week" Na rvm H-P, 101. ONLY Out, Ereb ►7a ;reµ Na i40a.yr INSPECTION Sells Sub- br Meow- Derr let FL. god III and Ft. REMARKS:. LIST OTHER ELECTRICAL DEVICES NOT SET FORTH ABOVE; DO NOT USE TH IS SPACE, This application is intended to corer tl.s allI listed rgyiPnrpnt to bar impeotad buI if at time of i You are aadgrixrd to make for irlsPection and adjust the fee to carer the additional nsprction Over" is found additional rquiPrnrot not eborr listed, SIZE OF epuiPtrlrnt. as prow,drd by the applicant. MAINS FEEDERS ELECTRIC SIGN TOTAL CHARACTER L..siMPS WATTS OF WORK EXPOSED GAS TURE SIGN CONCEALED TRANSFORMERS OF WORK TO BE f,.+" VA STARTED COMPLETED. IM f IfILRERI (CAPACITY)SERVICE OVERH SIZE OF SIGN EA UNDEROR D ENTERS !L l MAKER INSPECTION REQUESTED OF SIGN ON OR AS NEAR AS POSSIBLE AVOID DELAY BY GIVING FULL AND ACCURATE INFORMATION. ALL SPACES NEW OLD MUST BE FILLED IN OR APPLICATION MAY BE RETURNED. --ATE OF PRINT NAME AND ADDRESS NAME OF APPLICATION APPLICANT /'y `F SIGNATURE Y OF APPLICANT STREET ADDRESS f TELEPHONE # CITY OR OFFICE - J w"jr r 21P CODE LICENSE NO. WHEN APPLICABLE 46 EL (REV. 1/815) A SEPARATE APPLICATION MUST BE FILED FOR EACH SEPARATE BI.IFLDING OE D OULIER , INIC. (51% MG-3594 OE BOX 301, CLEVERQALE, N.Y. 12820 ow 40 -40 r-' L Nib ,a'a ----9►