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1987-924 dd R � CERTIFICATE OF OCCUPANCY TOWN OF QUEENSBURY WARREN COUNTY, NEW YORK �yy ate February 9.3 19 _ap lJ � o b �4a: �37-9t4 This is to certify work requested to be dome as shown by Permit No. has been compieted. This structure may be occupied as a � o Two Family Location 17 Queen Anne Court - Queen Victoria ' s Grant Owner Guyer Buiiciers , Inc * By Order Town Board TOWN OF QUEENSBURY Building & Wing Inspector BUILDING PERMIT �A TOWN OF QUEENSBURY Na. 87-924 WARREN COUNTY, NEW YORK Queen Victoria ' s Grant PERMISSION is hereby granted tom, OWNER of property located at 17 Queen Anne Court i Street, Road or Ave. in the Town of Oueensbury, To Construct or place a i of Two Family at the above location in accordance to application together with plot plans and ether information hereto filed and approved and in compliance with the Town of Oueensbury Building and Zoning Ordinance. 1 . OWNER'S Address is Guyer Builders Inc . 119 Dunning St . Ballston Spa , N . Y . 12020 �, n 2_ CONTRACTOR or BUI LOE R'S Name O Satye i W W 3. CONTRACTOR or BUILDER'S Address G'S Same ' 1 N rt 4_ ARCHITECT'S Name 5. ARCHITECT'S Address. '— V fd f6 6. TYPE of Construction -- (Please indicate by x) } Woad Frame ( 1 Masonry ( } Steel ( 1 m n 0 7. PLANS and Specifications rt rt No. 26 ' -6" x 35 ' - 7" as per plot plan , specifications and application including septic system and attached one car garage . MODEL K S. Proposed Use OF Two Family s $5 , 00 CIO $ 82 , 40 PERMIT FEE PAID - THIS PERMIT EXPIRES July 1 , 1y8i3 ,o.,, (if a longer period is required an application for an extension must be matte to the Building and Zoning inspector of the town of oueensbury before the expiration date_) a "rJ 31st December 87 w Dated at the Town of Oueensbury this Day of 19 F�, �..yy-��., � �, ,^y •-c SIGNED BY ! C - �. te for the Town of Oueensbury Building and Zoning inspector 'LL pL 4..411RtLLAGi.I ai �Yi/�7 • YMa"' a /wil Application No . fflown o keen3bter Permit Issued 19 1 t { BUILDING and ZONING DEPARTMENT Permit Expires 19 Bay and Haviland Road, R.D. 1 Box 98 Zoning Designation �'+�- � �^� � y: 4in Queensbury, New York 12801 Variance No . Site Plan Review NO . z Approved by . tv 7�' r APPLICATION FOR C t 'c'. i �+'`,+ - '� � r/�, .. 57ipaa- 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 submittedp and such special conditions as may be indicated on the Permit . The owner of this property isaGuyer Builders Inc P . O. Address 119 Dunning Street Ballston Spa , New York 12020 Tel . ( 518) 899-9161 Property Location . 17 Queen Anne Court Tax Map No . 121 / 4 / 2 Street number or building lot number subdivision name ( if applicable) IQueen Victoria ' s Grant THE PERSON RESPONSIBLE FOR SUPERVISION OF WORK AS REGARDS BUILDING CODES IS : Richard H. Gu er III ( 518 ) 899-9161 Name P . O. Address Tel . No . Name of builder Guyer Builders , Inc .Address 119 Dunning Street Tel . ( 518) 899-9161 Name of plumber Guyer BuIlderso nc •Address 119 ng Street Tel . Name of mason Guyer BUTLaers , nc *Address ng street Tel . - 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 dissensions ) ` 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 REQUIIREDp$OtPW . " Size of property 100± p an ft X 120 ft . * Existing building ( s) Size ft !{­­--N7X`ft . PROPOSED BUILDING AND USE : 3 Mod 1- * Existing building (s ) Use NIA Size of new strut a 26 ' -61ft x ft ' Foundation-,pier slab crawl/partial/full * Proposed building , seest nceot pfrroim property line circle one ) Front yard 30+ ft Rear yard 30+ ft No , of stories (habitable s ace ) 2 Height ( grade to ridge) 23 '�6" ft . * Side yards 15+ ft and 15+ ft * if on corner , setback from side street ft If residential , no4 of families of 2 Now of rooms (excluding baths ) " OCCUPANCY INFORMATION 7f bedrooms * PRIMARY BUILDING - k cf bathrooms One family dwelling his e r P ry heating system se r e ectri& =Two family dwelling c�sne BY& roll Ty of fuel Electrlclty * Multiple dwelling / Number of units No . of fireplaces to be installed Permanent occupancy Will a wood stove be installed? No NO * Transient occupancy Central Air conditioning? Business +r BUILDING STYLE, PRIMARY STRUCTURE „ Industrial * Other Ranch Contemporary i,o cabin if addition , what will use be? Raised ranch Mansion Duple Split level Old style Bungalow cApe Cod cottage Other * ACCESSORY BUILDING- Colonial Raw Town House * Detached garage/one car/ two car/ car ( CIRCLE ONE PLEASE ) * _Attached garage/one car/ two car/..one car Private storage building ESTIMATED MARKET VALUE OF " Other CONSTRUCTION " INpORIKATION ON - BUILDING SPECIFICATIONS , ON REVERSE SIDE OF THIS SKEET, To BE COMPLETED ! Form SPA 4/86 md-vl BUILDING PERMIT APPLICATION CONTINUED BUILDING SPECIFICATIONS : Type of construction , wood frame , fire safe , etco wood frame Will any second-hand or ungraded lumber be used? If so , for what ? no Foundation wall material concrete block Thickness $" Depth of foundation below grade (to bottom of footing ) 8'" fILlrl2ftttllft Will there be a cellar? 'no Heated or unheated? Floor sq. footage sq ft Will there be a basement? TIO Will any portion be used as living space? ( If so, what port sq. ft . - - Type of use? Type of roof - sloped flat/shed/other Material of roof Fiberglass shingles Size , wood studs "x 6 it spacing 24 "o . cv length 8 f't. exte3rr walls Joists ( floor beams) lst . floor N/A "X spacing "o . c s o . cw spaniel ft , . a Joists ( floor beams ) 2nd . floor �^" X��`" spacing �" � ft . Overlays ( ceiling beams ) 2 lox " spacing 24 "o . c . spar►12 ' -4ft . Roof rafters 2 "X " spacing`++ o . c . span `9 TO t , Roof trusses {pre-engineered) spacin �f " o , c . sp^a JAA ft . Exterior wall finish stained Of what material? 5 /80" x G ' x $ " tekture 111 Interior wall finish pain s eetrock If a garage is to be attached , describe materials to be used for FIRE SEPARATION : 1 /2" type "X" sheetrock Is there to be an opening between garage }and dwelling? yes If so will a Fire-rated door , enclosure , and self-closing device be provided? yes Will a flue-lined chimney be installed? No Height above roof N/A ft . Depth of chimney foundation below grade N A ft . Depth of fireplace hearth N/A ft . in . Water supply - Municipal or private well municipal SEPTIC SYSTEM _ Distance from ANY private well ( including adjoining properties NIA ft . (A separate application is necessary for any re air or new installation of septic system) See S . P . E . D . S . permit # 0202525 Town of Queensbury F F I D A V I T County of Warren 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 s ecifi d or not, and that such work is authorized by the owner . SWORN TO BEFORE ME THIS Signature �. _______ Charter , owner ' s �ag t rcnxrect, contractor ~ day of [ � l9 y Pub ic, toE . e f7P e P2atary Public, State of New York � ~ c.Ga, Qualified in Schenectady County Notary Public , W N . Y . 4717048 : r • * * ■ • * * * * * * s * * *Canrrssanxire* Sept*30 1* r * * * * * * ,� * * w * • * i SPECIAL CONDITIONS OF THE PERMIT : Poe TOWN OF QUEENSBURY WARREN COUNTY * NEW YORK ,application for : BUILDING PERMIT IN COMPLIANCE WITH THE NEW YORK STATE ENERGY CONSERVATION COME A permit must be obtained before beginning work . #NSWSR ALL of the followings ; & gross floor area 1C340 S . F. 2 . Type of heat Baseboard electric 3 . Iu the building mechanically COOIO47 No 40 percentage of area of windows and doors 12 ' 33% ,a . Over 16 % , Only 1 . Uo value of gross area of walla * roof/ ceiling and floors exposed to ambient conditions 2 . Floor over heated spaces YES No a . Are foundation walls insulated ? YES NO 1 . If YESg what is the R value ? 3 . Slab an grade YES N.Q 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 $ . Under 161 Only 1 . R value of roof and floors exposed to ambient conditions R-38 2 . • R value of exterior walls V R-23 . 5 U. =0 . 04+ 3 . R value of glazed area U * =0. 30 4 . R value of doors R-14 . 9 (U=0 .06) 5 . R value of floors over unheated Spaces 6 . R value of slab edge insulation - unheated slab N/A 7 . R value of slab insulation •- heated slab i2 . 5 8 . R value of heated basement/ cellar walls ( above grade ) N A g . R value of heated basement/cellar walls ( below grade ) N/A 10 . Type of insulation Fiberglass CowMawwwwww Controls 1 . Thermostat maximum heat setting D . Duct SXstems NIA 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 E . Piping Insulation NIA 1 . Size of hot water or cooling carrying agent pipe 2 . R value of pipe insulation 1* . Service Water [seating 16 performance efficiency NIA .' 2 . Temperature control setting maximum Monona G . For Swimmina Pool Only 1. Maximum heating NIA Telephone No . ( 518) 899-9161 mmmmmmaw ( applicant ' u a re ) w L -� rr v MIDDLE DEPAiRTMENT,.jHSSPEC1rj0N AGENCY, INC. w. +.IOO FiatlOae-Awnua;Cotlinq*w+oeil: i'i.J,'OB108 = ` of+� February 17 , 19 $9 rtif ie� that the electrical equipment listed has been examined and is approved as being in accord With the National 'Electrical Code, applicable governmental, utility and ,Agency rules. k' } ^. Dwelling owner: Guyer Ruilde'ra. Inc' � r -: Qccuparrcy . Single Family g ` } b C3ccuparri: 8 :" •ter ; f o- Wr en' �.Go) pertllieate covers tnr eleclrisN !gulp ment and Installation insoCGeeci this 17 Queen Anne. Court ; Q+seexuaiaur}r;• ( ' LOCaltiL]R; axes, li additional s ulpehent assfia he iull a d v of al d a ppli made to axlating system this CeitNicaie 8ha17 be null and void, and application eor inspection should be submitted prVmptly tolhis Agency 97 outlets ; 55 Receptacles ; 22 Fixtures ; ,Equipment: Holder of this is certificate should prgeeh0 same to his property insurance prover Service ; 7 Appliances {agent 0r Co m panVlaseuipenc9dl Cerli}I cat'on o}electncxl gqulpmen[xpproved 150 Amp s as specified, Guyer Builders ' '3nc Applicant: 119 Dunning StreetY:y-_ No . 15�028951 Ballston. Spa, NY i!020 J fi Foasl No. 703 EL k-43 a+wn O Queensbesre� ENT SOILDMG and ZC1N"40 DEPAFiTgoX 9$ Bay and Haviland h o Yor112801 Queensbury, SEPTIC DISPOSAL SYSTEM INSPECTION LO CAT ION i �S` PERMIT Na. pATS - Clay, - _ ------- LoaI�► - l30 SAIL TYPE an ired? 14 YES percolation Teat Re percolation rate - Min/Inc TYPE o SYSTEM* en+3th al f field ■ tot Ay]soxPL an each. trench X'ength �' Tenches 17ept'h of Size of g vel_ er x�✓ p' LL Of} SEEPAGE PI t #� X f . Size- _�2 �f Gravel size Size Type Hlag . to tank i I TanX to to le /Pit nist. box top Partial Openings se ed? APJkTrpN`a ft. Y,pp,P.'T1013/ to tangy Foundati to �sc,rpti �- f : Foundati n to lot line Absorpt on ft. Separat on of Pits ON pR PER YY (circle one) TAC.ATI OF SYSTEM . side Right side Rear - Left Front , CICKMENT SYSTEM USE AppRpxiEL1 YE6S Enai g Ins actor of/86 and vl ,�pu.n ©� �ueensburr� BUILDING and ZONING OE D R ME T Bay and Havifand Road. R. 96 Queensbury. New York 12801 BUILDING INSPECTOR ' S REPORT NAME LC)CAT I ON Date perlltlt DIf� - AppROVED - YES N o rng/Pier Farms oundati.on waterproofing Back.fill Framing Roof ing Siding -- -- MasonrY veneer ^^-- Rough Plumbing Relief ValvesExt . porches Finished Floor interior Trim Stairs & Railin Cellar. Drain Ti-1 Concrete ��-- ulbq . Fixtures ,Gar . Fireproofing Sx7sar closers me7ke Detectors chimn[ Y IN SV I.AT I ON Foundation Floors walls Ceilinq FINAL ELECT ICAL INSPECTION f)RIVEWAY Ap RoVAL Floal B%xild g survey ------ Next scheduled in ecticn (call when ready ) IZeroarks- u xn9 nspector �E, and-vl TOWN OF QUEENSBURY BUILDING AND CODES DEPARTMENT BAY & HAVILAND ROADS QUEENSBURY, NEW YORK 12809- .f7 / TELEPHONE ( 518 ) 792-5832 BUILDING INSPECTOR ' S REPORT REQUEST FOR INSPECTION RECEIVED _. } _� NAME 7 LOCATION - DATE _ T,'07, PERMIT # ,APPROVED YES NO FOOTING/PIERS MONOLITHIC POUR FORMS FOUNDATION/D�LMP—PROOFING BACKFILL APPROVAL ROUGH PLUMBING FRAMING ELECTRICAL ROUGH�IN INSULATION: FOUNDATION FLOORS WALLS CEILING Lo, FINAL INSPECTION : CHIMNEY HEIGHT ROOFING SIDING EXTERNAL PORCHES/STEPS STAIRS—CLEARANCE & RAILS PLUMBING FIXTURES/RELIEF VALVE INTERIOR TRIM/PRIVACY DOORS'' FINISHED FLOORS GARAGE FIREPROOFING DOOR CLOSERS) — SMOKE DETECTORS FINAL ELECTRICAL INSPECTION FINAL APPROVAL OF CONSTRUCTION A .SIGNED CERTIFICATE OF OCCUPANCY MUST BE OBTAINED FROM THE BUILDING DEPARTMENT BEFORE THESE PREMISES ARE OCCUPIED! REMARKS: I SPECTOR TOWN OF QUEENSBURY BUILDING AND CODES DEPARTMENT BAY & HAVILAND ROADS QUEENSBURYo NEW YORK 32803 TELEPHONE ( 518 ) 792- 58.32 BUILDING INSPECTOR' S REPORT REQUEST" FOR INSPECTION REC,'EIVED NAME LACATION DATE } j ! PERMIT #i f APPROVED YES NO FOOTINGIPIERS MONOLITHIC POUR FORMS FOUNDATION/DAMP-PROOFING B)i cKFILL APPROVA,44' L OUGH PLUMBING i,,,,o'RAMING ELECTRICAL ROUGH-IN INSULATION: FOUNDATION FLOORS WALLS CEILING FINAL INSPECTION: CHIMNEY HEIGHT ROOFING SIDING EXTERNAL PORCHES/STE STAIRS-CLEARANCE & xLS PLUMBING FIXTURES/ ELIEF VALUE INTERIOR TRIM/PRI ACY DOORS FINISHED FLOORS GARAGE FIREPRO0 NG DOOR CLOSERS) SMOKE DETECTOR FINAL ELECTRICA INSPECTION -- FINAL APPROVAL F CONSTRUCTION t A SIGNED CERTIFICATE OF OCCUPANCY MUST" BE OBTAINED FROM THE ,BUILDING DEPARTMENT ,BEFORE THESE PREMISES ARE OCCUPIED !' REMARKS . UINSPECOR TOWN OF QUEENSBURY l� BUILDING AND CODES DEPARTMENT HAY & HAVTLAND ROADS QUEENSI4URY, NEW YORK 12801 TELEPHONE (518) 792-5032 BUILDING INSPECTOR' S REPORT REQUEST FOR .INSPECTION RECEIVED _ NAME LOCATION �2 zap �y DATE PERMIT it APPROVED YES INO FOOTING/PIERS MONOLITHIC POUR FORMS FOUNDATION/DAMP-4'ROOFING BACKFILL APPROVAAL ROUGH PLUMBING )'FRAMT NG ' ELECTRICAL ROUGH-Ilt , INSULATION: F ON FOUNDATI r' FLOORS WALLS 1 L CEILING FINAL INSPECTION: CHIMNEY HEIGHT ' ROOFING SIDING r EXTERNAL PORCHESISTEPS _......... .......� STAIRS-CLEARANCE & RAILS , - PLUMBING FIXIES/RELIEF VALT� INTERIOR TRIM PRIVACY DOORS FINISHED FLOS GARAGE FIREP OOFING DOOR CLOSERS) �- SMOKE DETEC ORS FINAL ELECTRICAL INSPECTION FINAL APPROVAL OF CONSTRUCTION A SIGNED CERTIFICATE OF OCCUPANCY MUST BE OBTAINED FROM THE BUILDING DEPARTMENT BEFORE THESE PREMISES ARE OCCUPIED! REMARKS : CIA ory� INSPEc R TOWN OF QUEENSBURY BUILDING AND CODES DEPARTMENT ,SAY & HAVILAND ROADS QUEENSBURYr NEW YORK I2804— TELEPHONE (5I8 ) 792-5832 BUILDING INSPECTOR ' S REPORT REQUEST FOR INS ECTION RECEIVED NAME L 4 LOCATION 1. rC� _ DATE / - PERMIT APPR(aVED YES NO FOOTING/PIERS MONOLITHIC POUR FORMS FOUNDATION/DAMP—PROOFING BB KFILL APPROVAL Loo�pppGH PLUMBING jL�RAMING ELECTRICAL ROUGH—IN INSULATION.- FOUNDATION FLOORS WALLS CEILING FINAL INSPECTION : CHIMNEY HEIGHT ROOFING { ' SIDING EXTERNAL PORCHES/STEPS STAIRS—CLEARANCE & RA BLS PLUMBING FIXTURESJRE IEF VAL %E INTERIOR TRIM/PR-TVA DOORS d �__ FINISHED FLOORS GARAGE FIREPROOFI DOOR CLOSERS) SMOKE DETECTORS FINAL ELECTRICAL SPECTION FINAL APPROVAL OF CONSTRUCTION A SIGNED CERTIFI ATE OF OCCUPANCY MUST BE OBTAINED FROM TH ,BUILDING DEPARTMENT BEFORE THESE PREMISES ARE OCCUPIED! REMARKS: d;cd-��q 1� r I PECTOR e45P, QLIP�k'" JL "iry1 BLIY LOIN G and ZONINGDEPARTMENT Say and Hawifand Road, R . D. 1 Bax 98 1' (]ueensbury, New York 12801 ✓ BUl L- DING INSPEC fOR ' S REPO NAME TION Date'GK- Permit No APPROVED - YES No Ling/Pier Farms Foundation waterproofing I3ackfi ll Framing Roofing Siding Masonry Veneer _ Rough Plumbing Relief ValVes I.xt , Porches Finished Floors Interior "Trim ."`' talrs & Railings cellar Drain Tile Concrete Floors Plbg . Fixtures Gar . Fireproofing Door Closers Smoke Detectors ; Chimney LAT I ON oundation ` Floors Walls ceiling_ FINAL EI•ECTRICAL IL3SPECTIC]P3 ,, l?RIVEWAY AppFLOVAL Final Building Survey Next scheduled inspection ( call when ready ) Remarks- g ding Inspector b/i3f and-vl _ 0unen � urt� ' r � • !` BUILDING and ZONING L]EPF{fiThAENT Bay and Haviland Road, R. E3, 1 Box 98 C]ueensbury, New York 12801 r f3C11 LIB S NC, INSPECTOR F 5 REPORT NAME E. l / LOCATION . �L � a'1lt .2 [� i7ate , / Permit NO . 71'1'itcSVLfJ* * yl:Sf * NC7 �,y'c5coti� sy/Fier forms l�oun{ia k ion waterproofing 11ackfiII framing Ftoo f i n g Siding Masonry V4.1neer Rough Vl. umbing Relief Valves Elxt . Porches Vinishecl Floors Interior 'trim Stairs & hailing Cellar Drair7 Til Concrete Floors 111L7g _ Fixtures Car . Fireproof ng Donr Closors Smoke Detect-0 c,himney IN rUL' JOTI(7N : Foundation 1-1oc�rs Walls Ceiling_ FINAL Fol F-CTRICAL 3NSPL:CTION�' --- DR1VKWAY APPROVAL Final Building Survey Next ct�eduled insPectior� ( cal- i wfren ready ) Remarks- r 13u i ].d i.f7c Ynspec. for r �rxr•. �, 1 - ..1 84JILDING DEPT_ COPY OF APPLICATION FORM 46.ELF NEW YORK BOARD OF FIRE UNDERWRITERS_ FILE THIS COPY WITH BUILDING DEPT. WHEN REQUIRED. TEMP. 7F DATE _. CITY OR VILLAGE Queenabury TOWNSHIP Queeimbury COUNTY STREET AND OR #19 � �, ��� ROAD AND POLELE NO. POLE NO BETWEEN WHAT TWO .�_ PRE SECROSS S OECATED? SECTION BLOCK LOT OCCUPANT'S BUILDING NAME OCCVPANCY OWNER'S NAME �p,,�,� �/ e �„ 7 y 16x AND ADDRESS �� �r„LiA.t.a��Sy .L.L1.Ca f ii� 1'h lnniT•a 5���@>t TE L, �' i ' CURRENT SUPPLIED BY FROM THEIR OFFICE BUILDING S NEW OLD CJ VYORK DEFECTS 1--1 IS NEW X2 ADDITIONAL Q REMOVED e. LIST BELOW ALL EQUIPMENT WHICH YOU INSTALLED (NUMBER OF OUTLETS No. of Fiatlrrea & BRANCH Luca- Lamp Raceptaces MOTORS HEATERS CIRCUITS OFFICE USE ONLY tioru Sluta Attaeh't Ceiling wall Recep'ls Switch Pendant Bracket No. Type Each No. East No• Ai3a4w" INSPECTION Out- Aside sub- base Base- In Fa. 2nd FI. 3rd Pl. REMARKS: LIST OTHER ELECTRICAL DEVICES NOT SET FORTH ABOVE' DD NOT USE THIS SPACE. This application is intended la cover the aluwa listed aqu ipment to be inspected but it as time Of inspection there is found additional equipment nah abare listed,You are authorisedsa to make the inspection and adjust the e to carer the additional equipment, as prori[/atl by the applicant. SIZE OF ELECTRIC SIGN MAINS a FEEDERS TOTAL LAMPS WATTS CHARACTER �a EXPOSED GAS TURF SIGN OF WORK In and service CONCEALED TRANSFORMERS OF VA WORK TO BE (NUMBER) ICAPACITYI STARTED COMPLETED SIZE OF SIGN SERVICE OVERHEAD UNDERQROUND ENTERS MAKER BUILDIN0_1. OF SIGN INSPECTION REQUESTED POSSIBLELEN ON SSB HEAR AS W111 Ca]1 whm ready NEW O OLD AVOID DELAY BY GIVING FULL AND ACCURATE INFORMATION. ALL SPACES MUST BE FILLED IN OR APPLICATION MAY BE RETURNED. PRINT NAME AND ADDRESS NAME OF DATE OF APPLICANT /'�f tieara �.�. 6 -fxLa APPLICATION �+ � STREET ADDRESS 'I '� O TLyz -ii 5 TELEPHONE # _ 899=97 Fj'I POST OFFICE TLea'1 '} as} v .t.,, Zip LICENSE NO. bkw ciar CODE] &MCI WHEN APPLICABLE AS EL (REV/ 1/85) A SEPARATE APPLICATION MUST BE FILED FOR EACH SEPARATE BUILDING �q 4 , a, 0 OOP 0 O o �s oe QUEEN VICTORIA'S GRANT QUEENSBURY, N.Y. ANNE f f f LT f f 3.5 8'-0 DIAMETER 9'- 0 DEPTH �T 0 o 35' �yof ,y5 100, looll M 87.71' 2000 9a I 1000, .101 120.0� .r- REFERENCE DRAWINGS SA SITE UTILITIES sEpfIC A WATER Von©usEN 4 STEVES SURVEY PLAN