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f CERTIFICATE OF OCCUPANCY
it TOWN OF QUEENSBURY
WARREN COUNTY, NEW YORK
Bate June 30 , 19 88
i
This is to certify that work requested to be done as shown by Permit No. _ . 87 755
has been completed.
This structure may be occupied as a Mbe-Family Dwelling
L�r Queen Diana Lane (Briarwood Close )
IAMOCation
j Owner U . E . C . Developtuent
By Order Town Board
TOWN OF QUEENSBURY
ipL
Suildi00 & Zoning inspector
BUILDING PERMIT
TOWN OF QUEENSBURY 87_ 755
No.
WARREN COUNTY, NEW YORRK
m
PERM ISSI ON is hereby granted to D . E . C . Development
OWNER of property located at Lot # 10 Queen Diana Lane (Briarwood Close ) Street, Road or Ave.
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_ -.
n
1 , OwNE R'S Address is 184 Din.sbach Rd .
Glens Falls , N . Y . 12801 r�o�
CD
ry
v
2. CONTRACTOR or BUILDER 'S Name
ac
Same
3. CONTRACTOR or BUILDER'S Address
r
rl[
4, ARCHITECT'S Name
t" O
H
� A
H t7
5. ARCHITECT 5 Addre a
F '
[7 >b
F WIM
G
W
6. TYPE of Construction — (Please indicate by X)
I Wood Frame ( i Masonry i i Steel I T to
7. PLANS and Specifications
No. 32 ' x 48 ' as per plot plan , specifications and application including Co
septic system and attached two car garage . `D
S. Proposed Use
One Family Dwelling P.
�c
5 . C /o m
129 . 00 XRKRXX, May 1 , 88
19
(If a longer period is required an application for an extension must be made to the Building and Zoning inspector of the (In
town of (lueensbury before the expiration date.i
Dated at the Town of Queensbury this 28th Day of October 19 87
SIGNED BY /e / e:z "Ae for the Town of Queensbury
Building and Zoning Inspector „ ,
TO BE COMPLETED BY BLDG . DEPT ,
Application No . L
fe7eurt o tteerl3 4er[� Permit Issued 19
BUILDING and ZONING DEPARTMENT Permit Expires 13
Bay and Haviland Road, R.D. 1 Box 98 Zoning Designation _J .'a f i
Ciueensbury, New York 12801 Variance i Li I, c� t� (� �Lt
Site P1 Revie No . - i OCT 2 $ 19$�
1°'F�.Pro d�.I2.rL= iPf, I '-= � ^! !_" `}c
APPLICATION FOR
EU I LD I NG 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 : CJ - Lo
P . D. Address f� 14 1 `��A� l XW Tel . . 0EA39 7AF?fe'so05`
Property Location ; Z,4!n) 1 -11117 /0 L.,ro Tax Map No . 3
Street number orbuilding lot number
Subdivision name (if applicable) u /21�.f J�C[ (' lrQsz
THE PERSON RESPONSIBLE FOR SUPERVISION OF WORK AS REGARDS BUILDING CODES IS :
Name P , O , Address Tel . No ,
Name of builder "I e * 5 r9 ad" Address Tel . $ .9�4F 04S dlycuc.-=
Name of plumber GWJLC Address ( /?bcs 4Ch,+L S? Tel . y f, r- 5x
Dame of mason^ 4V( ..f [`ayVe--*^r Address _:Iua !� / 1J Tel 53- vSz
NATURE OF PROPOSED WORK : * ZONING INFORMATION :
-Li�onstruction of a new building A PLOT PLAN MUST HE' PREPARED ANI7 SUBMITTEDo
_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 ST'RUCTURk:.i AFFECTED.
* of septic disposal area .
* COMPLETE INFORMATION REQUIRED BELOW .
Size of property tv!79b ft x ft .
Existing building ( s ) Size — ft X ft .
w
PROPOSED BUILDING AND USE : I * Existing building ( s ) Use
Size of new structure ft X 79 9Pf
Foundation-pier/slab/crawl/partia Proposed building , distance from property line
(circle one) * k -y
Front yard_ ft Rear yard / C) ft
No , of stories (habitable space) off- _
Side yards
Height (grade to ridge) ;ZO ft * {' ft and ft-- -
If residential , no , of families 1 If on corner , setback from side street — ft
No . of roonts ( excluding baths) OCCUPANCY INFORMATION
No, of bedrooms , r
No . of. bathrooms / y PRIMARY BUILDING -
Cc'[ Rc� * Orie family dwelling
Primary heating system
Two family dwelling
Type of fuel
No , o£ fireplaces to be installed * Multiple dwelling Number of units/
Will a wood stove be installed? Permanent occupancy
Central Air conditioning? Transient occupancy
Business
BUILDING STYLE, PRIMARY STRUCTURE i Industrial
Ranch Contemporary Log cabin * Other '
Raised ranch Mansion Duplex * if addition , what will use be?
Split level old style Bungalow
C" Ue God Cottage. Other ACCESSORY BUILDING-
(�Col� onial stow Town House _Detached garage/'one car/ twc. car/ car
( CIRCLE ONE PLEASE ) 1,/ ttached garaaie/one car/ wo ar/ car
* * * * * * * * * * * * * * * * * * Private storage building
ESTIMATED MARKET VALUE OF Other
CONSTRUCTION F —
INFORMATION ON BUILDING SPECIFICATIONS $ ON 'REVERSE SIDE OF THIS SHEE'C , TO BE COMPLETED :
Form BPA 4/86 and-vl
BUILDING PERMIT APPLICATION CONTINUED -
BUILDING SPECIFICATIONS :
Type of construction , od frame fire safe , etc .
Will any second-hand or ungraded Lumber be used? if so , for what ? A,3C7
Foundation wall material �C7t� �� 1 X C,C t Thickness r .
Depth of foundation below grade ( to bottom of footing ) Jc_r
Will there be a cellar?j Heated or� eated?`� Floor sq_ footage l-7c>c� sq ft
Will there be a basement . AN.� Will any portion be used as living space ?
( If so , what portion? _ __sq . ft . - - Type of use?
Type of roof— aped lat/shedbother. Material of roof
Size , wood studs " X^ `" spacing, "o . c . length 10 ft .
Joists ( floor beams ) lst , floor VR� "X !/C_a to spacing"o . c . sparf�ft .
Joists ( floor beams ) 2nd . floor o " X= " spacings"o . c . span_ /�, � ft .
Overlays ( ceiling beams ) "X " spacing "o . c . span_ ft .
Roof raftersZ"X„ r. '" spacing o . c . span Co ft .
Roof trusses (pre-engineered) spacing_ ^_,LZ" o . c , spanc:5147 ft ,
Exterior wall finish n, Of what material ?
Interior wall finish -T 443c_
If a garage is to be attached , describe materials to be used for FIRE SEPARATION :
F I ge Cry drE 5 T xex. :� _
Is there to be an orening between garage and dwelling?� If so will a Fire-rated
door , enclosure , and self-closing device be provided?
Will a flue-lined chimney be installed? P%.7 height above roof ft .
Depth of chimney " foundation below grade ft *
Depth of fireplace hearth ft . in .
Water supply pr ivate well
SEPTIC SYSTEM _ Dxstance from ANY private well ( IncludIng adjoining properties ft .
(A separate application is necessary for any repair or new installation of septic system)
Town of Warren
eensbury
County off Warren A F F I D R 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 _ ------ --____
Owner , owner ' s a t , arcnirect ,, ratractor
day of 19
Notary Public , Warren County , N . Y .
* * * * * * * * * * * * * * * * * ,r * * * * * * * * * * * * * * * * * * * * * * * * * * it *
SPECIAL CONDITIONS OF THE PERMIT :
---------------
By
F
• TOWN OF QUEENSaBURY
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
2 . Type of heat FLU LG
3o Is the building mechanically cooled ?
i� %jJQ
4 . 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
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 floov ?
4 . Is basement heated ? YES NO
a . R value of insulation
5 . Type of insulation
B . Under 16 % Only
1 . R value of ro and floors exposed to ambient conditions_
oh and -- -
2 . R value of exterior walls -a /
3 . R value of glazed. area
4 . R value of doors
5 . R value of floors over unheated spacesR
6 . R value of slab edge insulation - unheated slab IUA
7 . R value of slab insulation - heated slab_ ,-) , r�
8 . R value of heated basement/ cellar walls ( above grade ) /'"�. y
9 . R value of heated basement/cellar walls ( below grade )
la . Type of insulation
Co Controls
1 . Thermostat maximum heat setting
Do Duct Systems
1 . Is duct system installed in unheated spaces ? YES
a . If YES , Revalue of duct installation
M . 9 value of duct in other areas
E . Ring maul ate_Lion
it size of hot water or cooling carrying agent ,yiye
2 . R value of pipe insulation
F . Service Water Heating eTQ
1 . Performance efficiency 70
2 . Temperature control setting maximum 4VO44
G . For Swimming Pool Only
le Maximum heating
Telephony No . �d S" -t�, 3 _ --
( applicant ' signature )
APPLICATION FOR SEPTIC DISPOSAL PERMIT
OUeLDING an* ZONING DIE PARTIVENT
Bay and Haviland Road- R.D. 1 Sox $8
Quee^tsbury. Nem York 12801 DATE lc' ! 7
f -
LOCAT 10N OF PROPERTY FOR
1 NSTALLATI Qhf /� I Rl I G115Cf l�/ � 1/ � � ,
OWNER ' S MAMA,_-s r' 'r i� rc.' []
ADDRESS /1 �jI l N l rt]r+ J�3.9�G Je a c n /rI_ T EL 2. 5�- 0463 3
INSTALLERS NAME {.y ,c ,rYl � TELi'7 �, `S'�
Number of bedrooms ( residential only)
Total daily flow ( compute @ 150 gal per bedroom)
Topography : Flat Rolling - Steep slope - ( circle one ) % of slope
Soil nature : San - Laam - Clay - OtherDepth fte
Ground water -At what depth?. //U+o'tVE ft .
Bed-rock or impervious material - .At what depth? , )o /y_u ft -
Percolation test Not required Required - -Rate fd&--o ,INi min-inch .
Domestic water supply - unicipal well - Other
Separation - Watersupply ( if well ) from Septic absorption
Proposed System : Septic tank _..LQoo gal . ( ZSinimun size . 1000 gal . )
Tile Field - Each trench �p ft . Total system legnth :20c�+ ft .
Seepage pit ( s ) Number of Size each ft X ft
Size of stone to be -used Depth or thicknessft .
ImPORT,ANT ! !
On a separate piece of paper , submit a diagram of the proposed system
with all dimensions shown ; including distance from any structure ,
distance from property lines and from ANY DOMESTIC WATER. SUPPLY or
share - line of lake * stream , pond ar wet - landInclude all dimensions of
the system , itself .
1' }: ,^ Z` c= 3' G .e L ": F" * EL= ?. .^. .. Y' 7. F £ 2aE ixfi G1. ..� GC7 'C &
to abide b ;? th & sC a >Ad a 'c T requirements cf The Toe:+n of Cueen : Lure
Sanitary Sevooe LiSPasa "c Ordira ?icc .
Sioncture: D ]'C £ 1rt771F t• LP � R7' £ C >;
05 / 86 Ind / vl
Section I1 SQ tic ' Syste-m rns ections ;
A . All applications for septic system installation ,
alteration or repair , as recxuired by the Town of
4ueensbury Sanitary Sewage ordinance , shall be
submitted to the Buildina Department at least
24 hours before start of construction and shall
include a plot plan s:howinge
1 ) the proposed location t>f 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
F3 . Pto system ,shall be covered before inspectic:n and
approval by the Building tnsp,ector . Failure to
comply with this reo^uirement may result in the
uncofine Bring of the system by the installer and a
fine of up to $250 . 00 .
C . An approved copy of the plot plan shall be
available on the construction site . Failure
to produce said plot plan at time of inspection
may result in an immediate work stoppage .
D . Should unforeseen problems during construction
Prevent proper installation , alteration or
repair of an approved system , a new proposal
must be submitted to the Queensbury Buildina
Department before further construction .
. ' r
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1
• I
a . ° 231 3 TFJE NEW Y'ORK BOARD OF FIRE UNDERWRITERS
BUREAU OF ELECTRICITY 0
41 STATE STREET, ALBANY. NEW YORK 122+07
Date UUl y 80 1988 Application No. on file O 3 2 U 41 !. S 6 A f f r 2 f]
THIS CERTIFIES THAT
only the electrical equipment as described below enad inter by the applicant named on the above application number in the premises of
DEC Development Lett. # 10 15 Queen Diana Lane Queensburyr New York dwell .
�.��{ out s �,dle~
in the fettawing location, LT Basement 01st Fl. � Tied Fl. Section Block Lot
was examined on 6 . 27 . 88 and found to be in compliance with the rcquirements of this Board.
FIXTURE FTACUts s1NITCl1Es FIXTURES
ET RANGES Ce7elECING EECifS OVENS D15H WASHERS EXHAUST FA1VS
OUTLS IF/[ANDESCENT Fl'C' �ENT AMT. K. W. AMT. K. W. AMT, K-W. AAAT, K. W. AMT, FI P_
DRYERS FURNACE MOTORS l4TYRE APIPUANCE MEMft SiNICIAL4111CO"I irtme ctociKs I JUNITHEA11IRS *AUITFOUT T DIMMERS
a" H. P, GAS H. P. T. A. AAMT. AMP- AMT. Amn. TRANS. AMT. H. P. Na. �^�RT AMT, I WATTS
1 1
1 hWt # 1
SERVICE Df NO. OF S E R V I C E
AMT. AMP. TYPE 1 1 7VY 1 1' 3W 9 X 3w 3 .ir rvr NO. P" ATOF Cc G- D. PIO. Or H$r LM Of-HW 04 NO. OF NEUTIALS OF i iriiwt
1 200 Cb 2 / ! I
OTHER AFFARATUS, E lec . Room HeLa t er s i 3 / 2 . 0 r 4 / 2 _ 6 r 2 / 1 . 7 5 . r 2 / 1 . O r 3 / , 5
3 -gfcl
1 - zmoke detector
Richard Rosettl
423 N*w Karnear Rd . r/
Albany , NY 12205 1239 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 SUILDING DEPARTMENT. THIS COPY OF CERTIFICATE MUST NOT BE ALTERED IN ANY MANNER.
. own of Q"eenjl"ry
BUILDING and ZONING DEPARTMENT
Bay and Wavitand Road. R.D- 1 Box 98
Queensbury, New York 12801
ILD,:
ING INSPECTOR ' S REPORT
NAME (�
LOCATION
Date _ b�/= y Permit Now
APPROVED* ^* YES* NO
Footing/Pier Forms
Foundation
waterproofing
Backfill
Framing
Roofing
Siding
Masonry Veneer
Rough Plumbing
Relief Valves
Ext . l'orches
Finished Floors
Interior "Trim
Stairs & Railings
Cellar Drain `File
concrete Floors
f'lbg . Fixtures
Gar . Fireproofing
Door closers
Smoke Detectors
Ch J.mnIcy
INSULATION :
Foundation
Floors
walls
Ceiling
FINAL ELECTRICAL NSPECTION
X'ItIVEWAY APPROVAL
XFinal Building Survey
f Next scheduled inspecCion ( call when ready )
Remarks-
Building nspe for
6/66 and-V1
BUILDING and ZONING DEPARTMENT
Bay and Naviland Road, R. D. 1 Box 98
Queensbury, New York 12801
SEPTIC DISPOSAL SYSTEM INSPECTION
NAME
LOCATION 07
DATE /
� �',`- PERMIT NO
SOIL TYPE - Sand - Loam - Clay -
Percolation Test Required? YES - NO
Percolation rate - Min/Inch
TYPE of SYSTEM:
Absorption field , total length
Length of each trench
Depth of trenc s
Size of gravel SEEPAGE PITS L3 er o£) w
Size- ft. X _ f t.
Gravel size pp
PIPING : Sizf{�-
Bldg . to tank
Tan} to dist . box
Dist _ box to field] Partial
Openings sealed? YES O
LOC,A.TION/SEPARATIONS : c f t.
Foundation to tank ft _
Foundation to absorpti ft .
Absorption to lot lin
Separation of pits £t.
O1V OE' SYSTEM PROPER ircls,, one)
ront - Rear - Left side ig
sid
OI3TS : 444
/
SYSTEM USE APPROVED Y
Bui d ng Inspector
01/86 and V1
BUILDING and ZONING DEPARTMENT
Bay and Havifand Road, R.D. 1 BOX 98
Queensbury, New York 12801
BUILDING INSPECTOR ' S REPORT
NAME ��
LOCATION A ~
Date 1/ Permit Nco l f�
APPROVED - YESJ NO
Footing/Pier Forms _
Foundation
Waterproofing
Backfill
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
INSULATION :
undation
Floors t
r
Walls
Ceiling
FINAL ELECTRICAL SPECTION
DRIVEWAY APPRovAL
Final Building S ruey�.......--
Next scheduled inspection (call when ready )
Remarks-
Building In ector
6/66 and-vi
< r down of Queen .s ury
BUILDING and ZONING DEPARTMENT
Bay and Haviland Road, R. D. I Box 98
Queensbury. New York 12801
BUILDING INSPECTOR ' S REPORT
NAME D ,�Orl J6 --�
Aj
LOCATION
G.
Date ,- � / e _ Permit Nov o /
* * w w w w a * w w w x rr * w w * w w w x * w
APPROVED - YES NO
Footing/Pier Forms
Foundation
waterproofing
Backfill
Roofing
Siding
Masonry Veneer
Rough Plumbing
Relief valves
Ext _ Porches
Finished Floors
Interior Trim
Stairs & Railings
.Cellar Drain Tile
Concrete Floors
plbq . Fixtures
Gar . Fireproofi g
Door Closers
Smoke Detecto s
Chimney
INSUI.ATION :
Foundation
Floors
Walls
Ceiling
FINAL ELF TRICAL INSPECTION
DRIVEWAY PPROVAI,
Final Bui ding Survey
Next s+chedu , ed inspection (call vjhen ready )
Remarks-
C:�Lt:).S I A
Building Inspecto
G/66 and-vl
f l /[ocvn of Queen.s6ury
- BUILDING and .ZONING DEPAFiTMENT
ay and Haviland Road, R.D. 1 Box 98
Queensbury, New York 12801
ILDING INSPECTOR ' S REPORT
NAME '�)
LOCATION
�r
Date f r Permit No .
✓ — APPROVED - YES NO
F ting/Pier Forms
o dation
Waterproofing
Backfill
Framing
Roca f ing
Siding
Masonry Ve eer
Rough Plumbing
Relief Valve
Ext , Porches
Finished Floor
Interior Trim
Stairs & Railings
Cellar Drain Tile
Concrete Floors
Plbg . Fixtures
Gar _ Fireproofi
Door Closers
Smoke Detector
Chimney
INSTILATION z
Foundation
Floors
Walls
Ceiling
FINAL ELECT AL INSPECTION
DRIVEWAY APPR VAL
Final Building Survey
Next scheduled inspection (call when ready )
Remarks-
01C
Building Inoft3tWtor
+6/86 and-vl
j[ ! lie awn o/ Queensberry
BUILDING and ZONING DEPARTMENT
Bay and Haviland Road, R. D. 1 Box 98
Queensbury, New York 12801
BUILDING INSPECTOR ' S REPORT
NAME A4'.__%'...t°',L'.,. �
LOCATION �[
Date // /1'/ ram Permit No .
r ✓ = APPROVED - E
�dotingfPier F
Foundation rms
Waterproofing
Backfill
Framing
Roofing
Siding
Masonry Veneer
Rough Plumbing
Relief Valves
Ext . Porches
Finished Floors
Interior Trim
Stairs & Railings
Cellar Drain Til
Concrete Floors
Plbg . Fixtures
Gar . Fireproof ng
Door Closers
Smoke Detect s
Chimney
INSULATION :
Foundation
Floors
Walls
Ceiling 44
FINAL ELECTRICAL INSPECTION
DRIVEWAY APPROVAL
Final Building Survey`_
Next scheduled inspection ( call when ready )
Remarks'-
AS
! /f y6of
e III
C•
Building spector
5f 86 and-vi
BUILDING DEPT. COPY OF APPLICATION FORM 46-EL, NEW YORK BOARD OF FIRE UNDERWRITERS.
FILE THIS COPY WITH BUILDING DEPT. WHEN REQUIRED, II
CITY OR 7EYP. s DATE
VILLAGE
TOWNSHIP COUNTY
ROAD AND PALE no
CROSS STREETS
T WHAT TWO '�' '� P LE NO.
PREMI E -EE7STED7 -11
OCCUPANTS ! S TION B OCK
NAME BUILDING
OWNERS NAM OCCUPANCY
AND ADDRESS +rr x/ �i iI' ..:� /"J }"1 l•. '
SUPPLIED 'l.l - TEL.
BY r FROM THEIR
BUILDING �¢t OFFICE
IS NEWy_�„ OLO WORK DEFECTS
IS NEW `-�, ADOITIONAL ❑ REMOVED ❑
LOST BELOW ALL EQUIPMENT WHICH YOU IINSTALLED
NUMBER OF OUTLETS No. of Fixtures a AN[:FI
till
Lea. Larne Recsptodw MOTORS HEATERS
B
OHNnSkft C IRCUITR S Wok Rt S OFFICE USE Switch Pendent Braekrt Ne_ Typr ONLY
H.P. Ww{a
out- Each No. Each No AIIIIII INSPECTION
Bids
Sull
bbii
BeRr
xtent
tR Ff.
ate FI.
s.d F1.
REMARKS: LIST OTHER ELECTRICAL DEVICES NOT SET FORTH ABOVE:
DO NOT USE THIS SPACE.
This appIkiation is intended to eever the above-listed
You are authorized to make the re"110 ti to be {moPacted but if at time of inspection ;/tare w leu nd additional
insprctian and adjust the Ire to cevrr the additional r9uiPmMlt M]t above {fitted,
SIZE OF ^� equlpmenL w Provided by the apPliernt.
MAINS e.!' FEEDERS ELECTRIC SIGN TOTAL
CHARACTER LAMPS WATTS
OF WORK ,7 EXPOSED OAS TUBE SIGN
CONCEALNSFORMERS OF TiRK TO BE ED TRANSFORMERS VA
STARTED ., COMPLETED )NUMBER) {CAPACITY)
ENTERS
SERVICE GIVE HEAD UNDERGROUND AD SIZE OF SIGN
IL 1 _ MAKER
INSPECTION REQUESTED OF SIGN
ON OR AS NEAR AS L }
POSSIBLE i 1
AVOID DELAY BY OI VINO FULL AND ACCURATE INFORMATION, ALL SPACES NC�N ❑ OLD
MUST BE FILEED IN OR APPLICATION MAY BE RETURNED. DATE OF
NAME OPRINT NAINE A ADDRESS _ i APPLICATION
PL + -
APICANT lr y''J +,j,.7 I-' 1 � r C� 5iGNATV AE �.�+' /,.,ljf�—
y / 1 OF APPLICANT— `�'T. r-
STREET ADDRESS C �7 „'�v Vj�} F�yl - z f � j ^ ~i
POST OFFICE �,CITY ORx / fI�;L _�, .T..E[L`EPH}ONE �74` �'� -
_� CODE ``S -' 7 / LICENSE N PP ICABi_E
as 6L (REV, 1 86) A SEPARATE APPLICATION MUST BE FILED FOR EACH SEPARATE BUILDING
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