1989-095 [ . . - .. _ _ . ..iLr.,�3'•°yw;��r'T":-,y,a'c- -r:=.e, eyr.w.....,-. cr „'v: s yf'� e y
CERIaFICAtE
i
TOWN OF QUEENSBURY
WARREN COUNTY, NEW YORK
i
L�atc June 27 iq 89
6M "►
This is to certify that work requested to be done as shown by Permit No.
has been compietrd. C y �'y (?r i�1�-�l IN
Thiis structure may be occupied as a I k �` rr Ey �� z - 3 � a�1 l la,s-, -
J �
1,ocarion cl � ticlt i. Iii2lsa I]�' 4 CAW
�J C.I 4 .-• v
C Valk\ xd4z
0wner
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By Order Town Board
TOWN OF QUEENSHURY
Director of Bldg. & Code Enforcement
k
BUILDING PERMIT
x
TOWN OF QUEENSBURY �
No. 89 - 95 �
WARREN C[] UNTYO NEW YORRK a
�.a
PERMISSION is hereby granted to
l
In
OWNER of property located at _ r cat 5 N ; dci n Hi ] l 37 i�Lt> Street. Road or Ave. I
in the Town of Queensbury, To Construct or place a
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_
F2CONTR4ACTF'0
ERS Adress is
37 Hidden Halls Drive
Queensbury , New York 12804 0�
t�
t�
R or BUILUEn"S Name �
c&HXXHX Guilford Design ro
3. CONTRACTOR or SUILDER'S Address
80 Watering Pond Road
Guilford , C-L� . UG437
4, ARCHITECT'S Name
C1
S'r
l.n
N
5. ARCHITECT'S Address
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ru
B. TYPE of Construction — (Please indicate by X)
.`C
3dX) Wood Frame I ) Masonry i I Steel i ) ~
7J
Go
7. PLANS and Specifications tQ
26t x 40 , si. n le family dwelling as per plot plan , n
No_ g ' .
specifications , and application , including septic and attached
B. Proposed Use
Single Family Duelling L
Y-
25 . 00 C/o
255 . 00 PERMIT FEE PAID - THIS PERMIT EXPIRES October 1 89 79
(D
(If a longer period is required an application for an extension must be rrwde to the Building and Zoning inspector of the
to
town of Queensbury before the expiration data.) t7i
Dated at the Town of Queensbury this 2 4 th Day of March 79 9
'C
SIGNED BY for the Town of Queensbury
Building and Zoning 1 nspe or (U
F
N
.1 . W 9 O ,�, APPI. ICATTON FOR BUILDING AND ZONING PrRMITQUEENSBUR
Racgieved TOWN OF QPEENSBURY
RECEIVED
��'• t '"c' ' Reu.iewed
:so
MAR G 1 $9
J Fee raZd $
V-AIILDING AND CODES ' UlI 'Ai1"i' Tz.NT Date 744ueci 7BLD@V,.& 1GADE DEPT.
13AY and IIAVII.AJVD ROADS RJD 1 Fox 9a I"
0UrEN5t3URY. JVR1q V0RK 12804 PeAmit NO .
Tole (518) 792-5J332 >~xt 204
.r u t Yt r ! * 7f I ■ R r '+► rY ♦ w w tF w w ■ ■ w ■ r } } w w w ■ r r w x r r
A FIE- R HIT MUST Bq OBTAINED UEFORE BEGINNING CONSTRUC:TIC3tV . NO INSPECTIONS
WILL BE MADE UNTIL. API` LICnr;T JJAS RECEIVED A VALID BUILDINC PLRNIIT .
All applicable spaces on this application must be completed and the
s 'i " 'future of the applicant n►ust appear on the reverse side of this sheet .
]It Ye K X A di i1 7k 'l: it A J. * 7G k Ai # * * 1c %4 Yi yC 7k X X t * Ji YC 7G 7k 71C fi'i �G
'1' ]ie owner of this property is : ,�/
t' . O . Address rrr '7rzc q c a✓ loX' 1 rr" Y , Le e-e'"s tv / v- TEL . 7 ✓ 2
MAP NO . 3 �
11roperty location G 9 /
s property since October 1 , 1988 ? /
teas there been any split Or this y no
If yes , Planning Board Review is necessary .
SUBDIVISION NAME * IF APPLICAnLE LOT I�{J . w,
The person responsir'•b} le for supervision of work as regards Building Codes is
ADDR
NJ� MNAMEf�
S� f' . Q . iSs Elea NO
tdame Oi builder 'Address 3 -7 -o --r----. nr» �.r3 `1' --
tJ:�ine of Plumber S zve / T.ddress Tel �
Naa►e Of Masan Aildre3y "Tal 7 42 9b �
tigr%TtAE OF PROPOSED ¢ n.�•�•�' y� ZONs r:c INI*40RiU+TION ( Office use OD-IV )
vV/ronstrucciors of 4 Pt.nw ruildinci � ZONING D2SICNAT'ION OF PROPERTY
Adaicion to a Uuilairtg # PERMITTED PRINCIPAL. PERMITTED ACCESSORY
�Altur"Lion to a 1.:uilding `
( 1s0 Ct►:.1nq� to .:xt � rioc (limanuions] " REVIEW REQUIRED mat PLANNING BOARI] ZONING BOARD
Ocher cork (daL -.crjAlo) SITE PLAIN REVIEW # APPROVED DATE
e keC1SS ARL:A DO 1> ROPOSCD. !g;T tUCTURC '► VARIANCE # APPROVED PATE
lst Floor 6 sq ft . I;zo Remarks ;
2 nd Floor / � sq, if t . / ate' , COt•IP kLY'1 zFll•C7tutin'P.CC3N icwr„sU 13t1iC3 14LL.Cak.1 .
Size of PrOLWCty fG e'! ft x�Fc •
Other Floors; sq ft . o� S txi iti�txJ builJ!JLLJ ( Z; ) Si ::u t` t X rt .
( not Cellar or bassrnencl -e) ez W
TOTAL. FLOOR AREA �� �'� s�3 f tvoom
� c"xiil�g buil.tiny (:. ) U::.:
of new :;tructur.a .Z L ft k 4-V6 ft
t•'o%utd:acion-pier/ s1aL/Crawl/PD6rtiwl1!! ` laXc>Iwa�d buildingj distance from pxopurcy lir►u
Wirclu OnQ ) Front yard fe Rear yard /r � '~ ft
Noe of r&torj s (ktaUa c..blQ sl1uce3 r t t
* Sida yards f t :and
Iluighc (grade to tridq.: ) 2 (a ft , yr" on corner . uucbaok .frets side ,, ,CQt:L ec
If reuiduntial « no, oe falnilies I
tioge of rootas tcxaludinq b"tha) # INFORMATION
NFORMATION
sto . of budrooliks 4/ 6 RING
P12IMARX LCIIL.L)1NC:
No . of b tLltracsu►:: 2 - ...One f'w"ly dwelling
l'riW;Ary► huaciltir ::yiSql &At1 •rwQ sauuly dwulling
eryys;; of f al . at! 5n - rlultiplas awelling Mutnber of units,
No. of to ]uQ irt::c:sl3 ectgoo -
Netna:►r►us►t occ:uraxlGy
Will a wo4ad ::covQ tug iis : c:.11ud? H '� •l"ran: iunc nccuxyar►a1
CoinLr"I Air collrli.tiurxill ° .�+ � +
BulL.DING STYLC, PRIMARY STRUCTURE . 1' nduuurial
QC;1crr
tulteh Con"&Pq:or" ry Lo ,�,n callin lK .additiolt, wt►iaC will t1 :► b.:?
Yr ai;:i�d ranch tianuicut Dup1GzX •
Monello
iplit lov.:l 014 4cyla uu11LI" low No
` CGCt;afjJ DCtwr • ACCgCSSORY LIUILDZNG^
C ctlani:al tiQlrf - "l'p4rn arouse " 1g)"tachea g aralge/ane +Cur./' tWI
iar/ car
( G`IflCLt: G1n13: PLI:A.alG ! w =Actuchuu g aragu/o4w cur/ two :1r cot'
w r w r w ■ r 11 � .x ■ r w ■ + • w ■' 1ariVa �+: 5G[]r:atJ4 bullyding
L. UTI MATt� D MhFiKET VALUE OF Ochor
] NFORmATTON ON DUTLDTNC ,PnCIPTCATIONS , ON RL;VERSE SIDE: OF WIS f3tkl•:h"P, TO Be COMPL ETV0 t
Form DPA 20/88 v1
BUILDING PERMIT APPl.1CATIO14 CONTINUED -
BUILDING SPECIFICATIONS :
Tyree 4f construction , wood frame , fire safe. etc .
Will any second-hand or ungraded lumber be used? If so, for whatr> � dd Z C.
Foundation wall material �i,, Cfelf ; ° d Thickness c� f
Depth of foundation below grade ( to botto-m of oot).ng )
Will there Tie a cellar?,� _3 Heated or unheated? U4A-e Floor sq. footage / � sq ft
Will there be a basement? Will any portion be used as living space?
( If so , what portion? sq . ft . - - Type of use?
Type of roof - Deed flat/shed/other Material of roof S'
Size , wood studs ` "X spacing"o . c . length ft .
.j oists ( floor beams ) lst . floor Z- "X u spacing /.G "o . c . span 3; ft .
,joists ( floor ]teams) 2nd . floor Z- " X7o •" spacing"o . c . span /�3 ft .
Overlays ( ceiling beams ) "X '• spacing "a . c . span f t .
Roof rafters "X " spacing o . ce span ft .
Roof trusses (pre-enginee:)ced) s acing G1 64 . span .z ( ft . -
Exterior wall finish ' ep ,4a ��-.--+' of what material?
Interior wall finish " bcc. .� ` .`� "
if a garage " s to bV attached , descrx e ma erials to be used for FIRE SEPARATION :
Is there to be an opening 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? 3 Height above roof ��� ft .
Depth of chimney foundation below grade ? ft .
Depth of fireplace hearth /� ft . Y in . p
Water supply - Municipal or private well ./01& /4 .J- 4
SEPTIC SYSTL'M _ Distance from ANY private well ( in luding adjoining properties _S700 ft .
(A separate application is necessary for any repair or new installation of septic system)
D E C L A R A T I O N
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 ORDINANCF,, 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. {�
Signature
Owner, owner's agent , architect, contractor
x x * x x * x r x * x * x x x x x * x x • * * x x x x x x • * x x x x x x x x * x x
SPECIAL CONDITIONS OF THE PERMIT :
ay------------ ----------- __... . . .
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 . Gross floor area ��
2 . Type of heat 63A 3
3 . Is the buildings mechanically cooled ? . ,rL/ �
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 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 exposed to ambient conditions_
2 . R value of exterior walls
3 . R value of glazed area J S� 7<-
4 . R value of doers
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 +ryr
8 . R value of heated basement / cellar walls ( above grade ) .,&- A�2
9 . R value of heated basement /cellar walls ( below grade )
10 . Type of insulation C/IcLlle ' ''S e,,e�
C . Controls
1 . Thermostat maximum heat setting r5b
D . Duct Systems
1 . Is duct system installed in unheated spaces ? YES
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 3P 7 �
2 . Temperature control setting maximum 136 "
G . For Swimming Pool Only
1 . Maximum heating
Telephone No . 7 �-
( applicant ' s signature )
TOWN OF QUEENSBURY
APPLICATION FOR
"= SEPTIC DISPOSAL PERMIT
DATEt / rt
LOCATION OF PROPERTY FOR INSTALLATION
Owner's Nameow 4�,% ( ?� /C -vf / S rTelephone: % j�p 3 ;7 9 5' Z__
Address: fi /�1`y eit e :/ ,rt ! a-
Installer's Name: "` T Telephone: 1�e 6
Number of bedrooms (residential only) /
Total daily flow (compute (d 150 gal per bedroom) C�
Topography: Circle on Flat Rolling Steep Slope % of Slope
Soil Nature: Circle one and oam Clay Other /Depth: �' Feet
Ground Water: At what depth? 3 Feet/
Bedrock or Impervious Material: At what depth ? r 6) Feet
Percolation test: Circle one: not required required rate min. inch.
Domestic water supply: circle one: unicipa Well Other r
If domestic water supply is a well:
Separation: Water supply from septic absorption feet
PROPOSED SYSTEM : Septic
Tank ,✓w' 0 0 gal. (minimum size: 1 ,000 gal.)
TILE FIELD: Each Trench 6 6r feet/'Total system length L feet
SEEPAGE PIT(S): Number, / Size each feet by feet
Size of stone to be use # / epth or Thickness feet
7r'r /-e�
I have read the regulation on the reverse side of this sheet and agree to abide by these
and all requirements of the Town of Queensbur Sanitary Sewage Disposal Ordinance.
SIGNATURE OF RESPONSIBLE PERSON:
__�/��
DATE: ""''
r
OVER
Septic System Inspections :
A . 1511 applications for septic system installation , alteration or repair ,
as required by the Town of Queensbury Sanitary Sewage Ordinance , shall
be submitted to the [wilding Department at least 24 houra before start
Of construction and shijil 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 ally water supply
5 . ) size and diizzensi.ons of all tanks , distribution boxes ,
rile fields and /or drywells
B , Nu 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 u13 to $ 250a 00a
C . An approved copy of the plot plan shall be available on tilt, 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 installa-
tion , alteration or repair of an approved system , a new proposal must
be submitted to the Queensbury Building Department before further
construction .
Town of Queensbury
BUILDINC and CODES DEPARTMENT
Bay and Haviland ]roads
Queensbury , New York 12804
Remarks :
.y
i
CERTIFICATE OF INSURANCE ISSUE DATE (MMIDWYY)
3 / 21 / 89
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS
N RIGHTS UPON THE CERTIFICATE HLDER. THIS CERTIFICATE DOES
McLaughlin Associates EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW NOT AMEND,
106 Wall St .
COMPANIES AFFORDING COVERAGE
Madison , Ct . 06443
COMPANY A
c+aoE SUB-CODE LETTER Shelby Insurance
COMPANY
INSURED LETTER
Guilford Design COMPANY C
80 watering 'Pond Rd . LETTEA
Guilford , Ct . 06437 COMPANY
LETTER p
COMPANY
LETTER
COVERAGES
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
DO TYPE OF INSURANCE POLICY NUMSER POLICY EFFECTIVE POLICY EXPIRATION ALL LIMITS IN THOUSANDS
LTR DATE (MMiDD/YY) DATE. (MMIDO1YY)
x GENERAL DABILITY ,r / GENERAL AGGREGATE 3
COMMERCIAL GENERAL LIABILITY A C G 6 3 3 9 6 0 2 7! / 2 2 // B1 8 7 / 2 2 /r 8 9 PROD UCTS-COMPIOPS AGGREGATE $ 1 , G 0 G
CLAIMS MADE x OCCUR. PERSONAL A ADVERTISING INJURY S 11 0 C
OWNER'S & CONTRACTOR'S PROT. EACH OCCURRENCE Y 1 } 000
FIRE DAMAGE (Any one fire) S 50
M MEDICAL ESOP ENSE (Any one person) S 5
AUTOMOBILE LIABILITY COMBINED
SINGLE 5
ANY AUTO LIMIT
ALL OWNED AUTOS BODILY
INJURY $
SCHEDULED AUTOS (Per person)
HIRED AUTOS BODILY
INJURY S
NON-OWNED AUTOS (Par accident)
GARAGE LIABILITY PROPERTY
DAMAGE $
EXCESS LIABILITY EACH AGGREGATE
OCCURRENCE
$ S
OTHER THAN UMBRELLA FORM
STATUTORY
x WORKER'S COMPENSATION
AND Aw C6339601 —/I / 22 // 88 J / 22 ,✓ 69 100 (EACH ACCIDENT)
S 500 (DISEASE—POLICY LIMIT)
EMPLOYERS' LIABILITY
$ 1 G G {DISEASE—EACH EMPLOYEE
OTHER
DESCRIPTION OF OPERATIONSILOCATIONS!VEHICLES/AESTRICTIONSISPECIAL ITEMS
CERTIFICATE HOLDER CANCELLRTIOhI
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
Paul Cordes EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO
37 H i d d e n H I l 1 s R d . MAIL DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
Q u e e n s b u r y , N Y 12801 LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
ACORN 25-S (3/88) � __ OACORD CORPORATION 1988 !
CERTIFICATE OF INSURANCE ISSUE GATE (MMIppIYY)
3/22/89 r
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS
NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND,
NOFM-MM INSURING AGENCY INC EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW
Po BOX 90
WUTEHALLr NY 1288'7 COMPANIES AFFORDING COVERAGE
LETTER Y A U IIL'ED ��+CI.E.�"J r"�I��� Sc '��i�[.�. 7�'�
CODE SUB-COOS
INSURED
LETTER COMPANY B F'I1EN I ' S FT
JND
�T 7 F' bQ%SCNRY 0CNTRACwMPS o INC a COMPANY c
& lumelEm THoI%Q\S LETTER
B0X 33 COMPANY
MCAALE GRANVILT NY 12839 LETTER
COMPANY E
LETTER
CO►rERAOES
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES- LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID_CLAIMS.
CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION ALL LIMITS IN THOUSANDS
TR DATE (MWDDiYY) DATE (MMIOOIYY)
GENERAL LIABILITY GENERAL AGGREGATE $ 600 ,
A X COMMERCIAL GENERAL LIABILITY IMP077482306 Ol 8/8 /88 8 /!8 /89 PRODUCTS-COMPFOPS AGGREGATE $ 600 r
CLAIMS MADE X OCCUR. J / / PERSONAL 3 ADVERTISING INJURY $ 3 •00 v
OWNFR'S S CONTRACTOR'S PRAT. EACH OCCURRENCE $ 300 ,
FIRE DAMAGE (Any one lire) § 500
MEDICAL EXPENSE fAny one Pelson) s CJ
AUTOMOBILE LIABILITY COMIMNED
SINGLE s
ANY AUTO LIMIT
ALL OWNED AUTOS 1BODILY
INJURY s
SCHEDULED AUTOS (Per Person)
HIRED AUTOS BODILY
INJURY s
NON-OWNED AUTOS (Per soc denll
GARAGE LIABILITY PROPERTY $
DAMAGE
EACH AGGREGATE
EXCESS LIABILITY
OCCURRENCE
s s
OTHER THAN UMBRELLA FORM
STATUTORY
WORKER'S COMPENSATION
8 AND 2 38 9W 80354461 8/8/88 8/8/89 § loof (EACH ACCIDENT)
s 500 r (DISEASE—POLICY LIMIT)
EMPLOYERS' LIABILITY lJ
s 100 (DISEASE—EACH EMPLOYEE)
OTHER
DESCRIPTION OF OPERATIONS!LOCATIONS/YEHICLESlRESTRICTIONS/SPECIAL ITEMS
. . .. W ... .. . ... ._ .... .. _ _-.._ . . . .. . .... . .
CERTIFI_CA__TE. . HOLDE_R CANCELLATION
Tcm OF Qj SBuFff SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
BUILDINGS o EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO
D" P144(y HATIIAMD ROAD MAIL DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
QUEENSBUR'Y, NY 12804 LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALT. IMPOSE NO OBLIGATION OR }
LIABILITY OF ANY KIND UPOWCWAQkjPAjjtYjjjfi)Q♦�flkTd%!f ff ENTATiVES. {
AUTHORIZED REPRESENTATIVE �( ++ v
ACORD 25-S (Waa) �ACORD CO ORATION 1988
r. r
cKorf f • • • • ■ ■ f • T_ 01■ i f
i ■ ! i ■ f f # • i ■ • • ■ f
NAME ANDAODI1 OFAGsNCY .� COMPANIES AFFORDING COVERAGES
A Jack Robinson Assoce �li4a LETTER
A
t�
Evergreen Plaza, Aviation Rd.
P.O. Bout 4749 M 798-48U3 COMPANY- -
ueerlsbu N.Y. 12801 LETTER B
NAME AND AaDAESS 4F INSURED _ ,t^ti
COMPANY 4
�::"✓': _ _ .. �. . LETTER
COMPANY
f s . wS�rrl� Ylj, KB. .�. � . LETTER LJ
S,�r+• --B.ellly-�:�2e G't. '1C _ � �„a,,, . =-.t {', COMPANY E. ..
15 Willow Road - _.
Thla la to tlyBLLi Rt19+ bj In IBAta �` lov} n issued to the insured named above and are In force at this time. Notwithstanding any requirement,
term or condit Ion of any oorrt ac or of her document with respect to which this cart ific ata may ba Issued or may pertain, the insurance aifordetl by tyre r7allcfes dascnbad
herein Is Subject to all the terms exclusions and conditions of such policles.
LIMITS OF LIABILITY IN Tt4OUSANDS (om
G API YER _ POLICYNUMBER " POLICY EACH AGGREGATE
TYPE OF INSURANCE - - Fri PIRAT4ON DATE OCCURRENCE
GENERAL LIABILITY BODILY INJURY s
COMPREHENSWE FORM C C P 3 j 39938 3 s/ 1 1 / 8 9
PREMISES—OPERATIONS PROPERTY DAMAGE ;
EXPLOSION AND
COLLAPSE HAZARD
UNDERGROUND HAZARD
PRODUCTSICOMPLETED I
OPERATIONS HAZARD - BODILY INJURY AND f
- " CONTRACTUAL INSURANCE - - PROPERTY DAMAGE 1 000010100
BROAD FORM PAOPERTYq - .. COMBINED
,.DAMAGE
IN DEP.CONTRACTORS .
PERSONAL INJURY- _ , PERSONAL INJURY
AUTOMOBILE LIABILITY BODILY INJURY
_ .. .. 4EACH-YE�tsoNy-
�« COMPREHENSIVE FORM = yy n n 3 $ 3 / 1 1 fir ,$ 9 BODILY INJURY i •'0i�
OWNED 3 7 7 (EACH ACCIDENT] i
A PROPERTY DAMAGE
�i
HIRED BODILY INJURY AND
NDN-0YVNEO PROPERTY DAMAGE ;
COMBIN£D+f y ;
F XCESS LIABILITY BODILY INJURY AND
UMBRELLA FORM PROPERTY DAMAGE $ $
r�1 OTHER THAN UMBRELLA COMBINED
L-1 FORM
N WORKERS' COMPENSATiON �j t C� STATUTORY
and iCC31 ,� � 1 47 " 00 4r/ 26 /
EMPLOYERS' LIABILITY S EACH ACCIDENT}
OTHER ` r
DESCA IPTION OF OPERATIONS/IOCATIONSIVEHICLES
w -
Cancellation: Should any of the above described policies be cancelled before thra expiration date thereof, the Issuing company will
endeavor to mail days written notice to the below named certificate holder, but failure to mail such notice Shall im-
pose no obligation or liability of any kind upon the company.
NAME AND ADDRESS OF CERTIFICATE HOLDER October i 1 EJ B
DATE ISSUED'_
Town of Queanabttry .
Torun offices ���.�.�yfr� �
Bay Rgad AUTHOHIZIE ATIVE
Queeneburyv NY 12804
ACCORD it} (1.791 .
MIDDLE DEPART l p�•*JpN AGENCY. INC. � 7
9 oa kl • ra kja ito swaod. M ! .rs�aa
. '�` �• '+'r � = W ' . taaav Ivne 26 , 1939
r�- necl and
lie roved as being in accord
Qrtlfie� that select[9a6pii ableegove�rnmentaihas ,ute'i1 to%ands Agency rules.
God , app Y -
with the National Elects , 4
Paul Cordes r Oa
ild r dwelling
Owner:
Same
. CCLJ�?a Rt: ,fin 4 'cerClfical8 CC1VeIE ttiY 6lactr.c N- quiRm9nt and instalYahpn in trao this
LOeatipR: Lot 52 Hidd Eii s1 oafs. H additional equ'Pm'ane +► na nUIl6ndaod. ana a'PalGalDderor
existing sysfam tills cart]t'Ica}e thy to Phis Agency.
y in shoulI be sub nl�tted p Y
Y .. u� s f rt inS Lrran Ge carrver
() , ece C "aC les r - s� 7 �°. oldar a1 this caf4ilica[e anpuWent same to his 4rope Y
Equipment: 115 outlets ; SJ (agan5 or c om pony) as evidence tlrtifica5ion al electricalequ pment BPPraved
200 Amp Serve 7 AP pl lances ea sPscifisd.,.
l IV
FKeliy Electric o . 15 -022237
App►roant: Willow Road P3Y 12804 ____ w r
�Qeseansbury ,
i
N 'OE QUEENSBURY
LDING AND CODES DEPARTMENT
f & HAVrLAND ROADS
,EENSBURYo NEW YORK 1280k
ELEPHONE (518) 792-5832
BUILDING INSPECTOR' S REPORT
REQUEST FOR INSPECTI N RECEIVED
! NAME
LOCATION
DATE ^- - RMIT )/ � ry lj
APPROVED
YES NO
FOOTING/PIERS
MONOLITHIC POUR FORMS
FOU"NDAT X"ON/DAMP—PROOFING
BACKFILL APPROVAL
ROUGH PLUMBING
FRAMING
ELECTRICAL ROUGH N
INSULATION:
FOUNDATION 4
FLOORS
WALLS
CEILING
(,/FINAL INSPECTION:
CHIMNEY HEIGHT
ROOFING
SIDING
EXTERNAL PORCHESfES'TEP
STArRS—CLEARANCE:' & RAI
PLUMBING FIXTUROS/RELIE VALVE
INTERIOR TRIM/PRIVACY D RS
FINISHED FLOORS
GARAGE FIREPROOFING
DOOR CLOSER (S,J
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 OCCtTPIED!
REMARKS:
{
I SPECTOR
TOWN OF QUEENSBURY
BUILDING AND CORES DEPARTMENT
BAY & HAVILAND ROADS
QUEENSBURYa NEW YORK I280!&
TELEPHONE (518) 792-5832
BUILDING INSPECTOR ' S REPORT
REQUEST FOR INSPECTION RECEx ED
NAME Lawz
LOCATIONe�J7`
DATE j — PERMIT #
APPROVED
YES NO
FOOTINGIPIERS
MONOLITHIC POUR FORMS
FOUNDATION/DAMP�PROOFING
BACKFXI_.L APPROVA
ROUGH PLUMBING
ECTRICAZ
I NG r
ROUGH— N
LATION:
FOUNDATXON
FLOORS
WALLS
CEILING
FINAL INSPECTION:
CHIMNEY HEIGHT
ROOFING IL
SIDING
EXTERNAL PORCHESISTOttS
STAIRS—CLEARANCE &/RA LS
PLUMBXNG FIXTURES REL EF VALVE
INTERIOR TRXM/PR VACY RS
FINXSHED FL(X7RS
GARAGE FIREPR PING
DOOR CLOSER (S
SMOKE DETECFOF
S
FINAL ELF.C? I INSPECTION
FINAL APPROV CONSTRUCTI[JIuT
A SIGNED CERTIFICATE OF OCCUPANC MUST BE
OBTAINED FROM THE BUXLDXNG DEPARTMENT BEF`ORE
THESE PREMISES ARE OCCUPIED!
REMARKS:
Af
INSPECTOR
awn 0/ Queendhury
BUILDING and ZONING DEPARTMENT
Bay and Haviland Road, R. D. 1 Box 98
Oueensbury, New York 12801
SEPTIC�DISPOSAL SYSTEM INSPECTION
NAME 1 ee '.3' c
LOCAT I CN. ;'}r 74
nA`iCfO 7 PERMIT N(]. i
SOIL TYPESan Loam - Clay
Percolaton Test Required? YES - NO
Percolation rate - Min/Inch _
TYPE of SYlea
M:
Absorptioneld , total length --
Length of trench 4/62
Depth of tren es /_4.L� NI
Size of gravel_
SEEPAGE PITS*N er of) r`
Size- ft. X ft.
Gravel size -
Bldg . to tank.
Tank to list. box
Disto box to field/pi �r
Openings sealed? NO Partial
LocATZON/SEPARATIONS :
Foundation to tank vim. ft.
Foundation to absorption ft .
Absorption to lot line ft.
Separation of pits ft-
LOCATION 'XSTEM PROPER (circle one )
Front R Left side - Rig t side -
CC1M MENT _
SYSTEM USE APPROVED/YES„ O
Bui' oing Inspec or
01/86 and v1
TOWN OF QUEENSBURY
BUILDING AND CODES DEPARTMENT
BAY & HAVTLAND ROADS f�
QUEENSBURY, NEW YORK I28oi&
TELEPHONE (5I8) 792-5932
BUILDING INSPECTOR ' S REPORT
REQUEST" F91RN INSPECTION RECEIVED`
NAME _
LOCATION
DATE PERMIT # -
APPROVED
YES NO
FOOTING/PIERS
MONOLITHIC POUR FORMS
FOUNDATION/DAMP--PROOFING
BACKF'ILL AkPROVAL
ROUGH PLUMBIWG
FRAMING
ELECTRICAL ROU H-TN
INSULATION:
FOUNDATION
FLOORS
WALLS
CEILING
FINAL INSPECTION:
CHIMNEY HEIGHT
ROOFING
SIDING
EXTERNAL PORCHES/ TEPS
STAIRS-CLEARANCE
K& RAILS
PLUMBING FIXTUR S/RELIEF VA E
INTERIOR TRIM/ IVACY DOORS --
FINISHED FLOOR
GARAGE FIREPR FING
DOOR CLOSER (S
SMOKE DETEC RS
FINAL ELECTRIC L INSPECTION
FINAL APPROV'A OF CONSTRUCTION
A SIGNED CER FICATE OP OCCUPANCY MUST BE
OBTAINED FROM THE BUILDING DEPARTMENT BEFORE
THESE PREMISES ARE OCCUPIED!
REMARKS:
INSPECTOR
TOWN OF QUEENSBURY
BUILDING AND CODES DEPARTMENT
BAY & HAVILAND ROADS
QUEENSBURY, NEW YORK 12804-
TELEPHONE (518 ) 792-5832
BUILDING INSPECTOR' S REPORT
REQUEST FOR INSPECTION RECEIVED
NAME
LOCATION
DATE 6L / FERMIfi #
APPROVED
YES NO
FOOTING/PIERS
MONOLITHIC POUR FORMS
FOUNDATION/DAMP-PROOFING
SACKF'ILL APPROVAL
OUGH PLUMB£ G \ / Js
�RAMI NG
ELECTRICAL R H-IN
INSULATION:
FOUNDATION
FLOORS
WALLS
CE.LLING
FINAL INSPECTION:
CHIMNEY HEIGHT
ROOFING
SIDING
EXTERNAL PORCHESIST PS
....................................
STAIRS-CLEARANCE & RAILS
PLUMBING FIXTURES RELIEF ALVE
INTERIOR TRIM/PR VACY DOO
FINISHED FLOORS
GARAGE FIREPR ING
DOOR CLOSER (S)
SMOKE DETECTO S
FINAL ELECTRIC L INSPECTION
FINAL APPROVA OF CONSTRUCTION
A SIGNED CER FICATE OF OCCUPANCY MU VT BE
OBTAINED FROM HE BUILDING DEPARTMENT BEFORE
THESE PREMISES ARE OCCUPIED!
REMARKS:
INSPECTOR
TOWN OF QUEENSAURY
BUILDING AND COZIES DEPARTMENT
BAY & BURY NE ROADS
Qi1EENSBURYo NEW YORK 1280$-
TELEPHONE (5I8) 792-5832
BUILDING INSPECTOR ' S REPORT
REQUEST FOR INSPECTION RECEIVED
NAME
LOCATION
DATE PERMIT # �f ' af
r
APPROVED
YES NO
L.�i7TING/PIERS,
MONOLITHIC POOR FORMS
FOUNDATION/DAMP-PROOFING .
BACKFXLL APPROVAL
ROUGH PLUMBING
FRAMING
ELECTRICAL ROUGH ,iN
INSULATION:
FOUNDATION
FLOORS
WALLS
CEILING
FINAL .INSPECTION:
CHIMNEY HEIGHT
ROOFING
SIDING
EXTERNAL PORCHES/STEPS
STAIRS-CLEARANCE & RAI
PLUMBING FI TURES/RELIEF LVE
INTERIOR TRIM/PRIVACY DOO
FINISHED FORS
GARAGE FIREPROOFING
DOOR CLOR (S)
SMOKE DE ECTORS
FINAL ELECf-RSCAL INSPECTION
FINAL APPROVAL OF CONSTRUCTION
r
A SIGNED FERTIFICATE OF OCCUPANCY MUST BE
OBTAINED ROM THE BUILDING DEPARTMENT BEFORE
THESE PREMISES ARE OCCUPIEDI
REMARKS:
f ;
INSPECTOR
TOWN OF QUEENSBURY Izoo f
BUILDING AND CODES DEPARTMENT
BAY & HAVILAND ROADS r y_
QUEENSBURY, NEW YORK 128099
TELEPHONE (528) 792-5832
BUILDING INSPECTOR ` S REPORT
REQUEST FOR INSPECTION RECEIVED
NAME (ter
LOCATION J DATE f I PERMIT #� zfp r '"Jvj
APPROVED
YES NO
FOOTING/PIERS
MON LITHIC POUR FORMS
t,-r6&NDAT I'O N/DAMP—PROOF 2NG
BACKFILL APPROVAL
ROUGH PLUMBING
FRAMING
ELECTRICAL ROUGH—IN
.INSULATION:
FOUNDATION
FLOORS AT L
WALLS
CEILING.
FINAL INSPECTION: r
CHIMNEY HEIGHT a
ROOFING
SIDING
EXTERNAL PORCHESISTEP
STAIRS—CLEARANCE & RA, LS
PLUMBING FIXTURES/R4XEF '-5VALVE
INTERIOR TRIM/PRIVA Y DOO*
FINISHED FLOORS s�
GARAGE FIREPROOFI, G '•
DOOR CLOSER (S)
SMOKE DETECTORSi
FINAL ELECTRICAL NSPECTION
FINAL APPROVAL O CONSTRUCTION . .
1
A SIGNED CERTIFICATE OF OCCUPANCY MUST BE
OBTAINED FROM THE BUILDING DEPARTMENT BEFORE
THESE PREMISES ARE OCCUPIED!
REMARKS.
LtPECTCR
Ir
TOWN OF QUEENSBUR Y
BUILDING AND CODES DEPARTMENT
BAY & HAVXLAND ROADS
QUEENSBURY, NEW YORK I280$-
TELEPHONE (518) 792-5832
BUILDING INSPECTOR ' S REPORT
REQUEST FOR INSPECTION RECEIVER
NAME
DATE PERMIT # e
APPROVED
YES NO
,(+pOOTING/PIERS
MONOLXTHXC R FORMS
FOUNDA TION/DP—PROOFXNG
BACKFILL APPR VAL
ROUGH PLUMBXNG- 3
FRAMING
ELECTRICAL ROU —.IN
INSULATION: rA
FOUNDATION
FLOORS x`
WALLS
CEILING ,
FINAL INSPECTION: '
CHIMNEY HEIGHT
ROOFING
SIDING f
EXTERNAL PORCH /STE S
STAIRS—CLEARA E & RA LS
PLUMBXNG FIX RES/REL F VALVE
INTERIOR TRI{ /PRIVACY RS
FINISHED FLOORS
F
GARAGE FIREPROOFING
DOOR CLOSERS) _.
SMOKE DETECTORS
FINAL ELECTRICAL INSPECTION 3
FINAL APPROVAL OF CONSTRUCTIpN
A SIGNED CERTIFICATE OF OCCUPAN Y MUST BE
OBTAINED FROM THE BUILDING DEPARTMENT BEFORE
THESE PREMISES ARE OCCUPIED.!
REMARKS: + ,
INSPECTOR
APPLICATION FOR ELECTRICAL INSPECTION
PLEASE BEAR DOWN YOU ARE MAKING (4) COPIES r
MIDDLE DEPARTMENT INSPECTION AGENCY, INC.
National Headquarters
900 Haddon Ave., Collingswood, N.J. 08708
Date; r
City, Town or Township // CountyState
Location/Address
r7 (if Located in Rural Area - Please Attach Directions) pole # K
Owner Av„�
j
57
Occupied As `S' — -� Permit #Building: New l✓f Old Q
Occupant � -
Work Area in Buildin FIC}Or #, etc.J :
A . for: Wirin Serviced or: Readv for Inspection . c w .t . , -O
Fee Remitted - $ Cash Q Check Q M,O. Q Make Payable To : M.D. I.A.
Number of Rough wing Outlets Elect, Heat 500 750 1000 1250 150o 1750 2000 2250 2500 2750 3000
Switches J
Am Service Surface Unit ` s Lighting p• _. � Dishwasher Range
Receptacles Water Heater Air Conditioner ,._a ¢Dryer Pump
Number of Fixtures "' Oven Garb ge Disposal Wiring and Controls for Burner
/y Amp. Receptacles 3 G Fractional H.P. Vent Fans
Other Equipment:
MOTORS i) P, 1/2 1/12 1/10 1/a 1!6 1/4 1J3 112 3/4 1 1 �/z 2 3 5 7Yx 10 15 20 25 30 40 50 75 100
Mark Number
of Each Size
Applicant's
Signature T/A License # Permit #
Utility : ,/ M rx r'
Applicant"s Address : /r�r .'"`-�" ,_ 1NAM OFFICEtZ CATION
(State) 0 rr / ! r
# u t'y `l 7 9 ✓ {�ipl Z. Service R qugst
Phone #
Electrician : ��� 4 r t_
MDIA USE ONLY
DATE RECEIVED
DATE INSPECTED:
Correct Location : Same as Above [:::] or :
Red Notice Label �]
Rough wiring Outlets Surface Unit Oven
Switches Ran a Garbage Disposal
Receptacles water Heater Dishwasher
Fixtures Air Conditioner Dryer
Amp, Service Equipment Burner, Wiring & Controls for Amp. Receptacle
Amp. Service Conductors Pump Vent Fans
MOTORS H.P. 1/20 1/12 1/10 1/6 Mark Number
lfa 1/4 1/3 1J2 3/4 1 1% 2 3 5 7112 10 15 20 25 30 40 50 75 100
Patrick J r7aSI rI Elect. Heat
500 7S0 1000 1 1250 1500 1750 2000 2250 2500 2750 1000
' Fludsunalx, 3t 12839
. 51 /?9 -3473
ELECT
BICAL INSPECTOR
CERTIFICATIONS USE FOR INITIAL VISIT ONLY NOTIFIUCIATEAFEE
Q RW Progresso Inc. Q LKD Q Contracto
Q CFT Violation : work Comp, [� Inc.
Q LIA Owner
Q L/A
IPA Municipal'Date: Other Side Q Utility
Cut in Card 0 Temp # ,Date
I_ .I Final # Date INSPECTORS SIGNATURE
cn
tu
--------------------
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