1989-079 O s
CER.TH ICATE OF OCCL. PANC`117
TOWN OF QUEENSBURY
WARREN COUNTY, NEW YORK
Date_ t9m 23 19 9
,ADA. I rl
This is to certify that work requested to be dome as shown by Permit No. n n —"7 c#
has been completed.
This structure may be ocguQiOd as a l���
I..00ation .
L11 (��,'7 *..
Owner Irvro~ t Wc7oci Sc3�� w
By Order Town Board
TOWN OF QUEENSSURY
xiz
Director of Bldg. ok Code Enforcement
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BUILDING PERMIT
TOWN OF QUEENSBURY No. 89-79
WARREN COUNTY, NEW YORK 0
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PERMISSION is hereby granted to rQz:est Wood nnmtn s w
I
Ln
OWNER of property located at T nt ] l Q Oak TrPP Cirr-1 P Street, Road or Ave.
va
in the Town of Queensbury, To Construct or place a S i ng1 F+ Farm 131 ► wOl l i ng `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_
1. OWNE WS Address is
HC-02 Box 286P
Warrensburg , N _ Y _ 12885 lot
D
2. CONTRACTOR or BUI LDER'S Name (D
Self rot
d
3. CONTRACTOR or BUILDER "S Address
Same
fA
4. ARCHITECT'S Name to
5. ARCHITECT'S Address
O
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I-
6. TYPE of Construction — (Please indicate by X1 ~
C
TJMood Frame i 1 Masonry ( 1 steel { } O
AI
7. PLANS and Specifications
No. 28 ' x 67 ' single family dwelling as per plot plan ,
specifications , and applicationrincluding attached two car
N
8. Proposed Use
l—
M
Single Family Dwelling
25 _ 00 c/o
$ 223 00 PERMIT FEE PAID — THIS PERMIT EXPIRES October 1 1989
(If a longer period is required an application for an extension must be made to the Building and Zoning inspector of the U
town of Queensbury before the expiration date.(
Dated at the Town of Queensbury this 13th _ _Day of
r March 19 $ 9 �
SIGNED BY f-I for the Town of Queensbury y
Budding and Zoning I �''(, ~
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F'- F
•:$ tiC
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TOWN OF QUEENS}3URY APPILICATTON FOR BUILDIM0 AND ZONING PERMIT
-�<A R ev.i
y s Fit
Fee. Paid
F- ILDINf; AND CODES DI J'N't'i'! TIE 1'I` Ante Ta.aued
BAY and flAV.ILA4VF ROAMS RA Z Box 98
pUEENSBVRY, NEW YOORK ]. 2804 PeWPL� No .
Te] . ( 518 ) 792-5832 Ext -204
■ y * . * w w * t * * * * * w w a w w w w w as * w w ■ w ,. w ■ w * w x ►;
A PERrtIT maser Do OBTAINED BEFORE BEGINNING CONSTRUCTION o NO INSPECTIONS
le' ILL BE MADE UNTIL APPLICANT HAS R'RCEIVED A VALID BUILDINC PERMIT .
All applicable; spaces on this application must be completed and the
c0puature of the ap licant must appear on the reverse side at this sheet .
* I* A is X is * * * Q. " ". h * do ,% X It * is is I * 'k * * *
mill-Le owner of this property i s : �Ebp e.54— W ol)A gwrlej
P . O . Address S - 0�) LG0 z T C L .
A]C MAP NC? . / I
Property location ,,(ilT
ltas there been any split of this property since October 1 . 1989 ? yes/ no
��
1f yes , Planning Board Review is nee{ � ary trr� LOT NO , 110
5U13DIVISI +DN NAME , IF APPLICABLE
The person responsible for suPurVision of work as regards Building Codes is :
f
P . G . ADDRCSS TEL . No .
NAME AL Tel '✓;
tJame of builder f '°+
rJ ama of Plumber
Name of Kason Address
NATURE Or PROPOSED l,60RF. : ZONING: INFO RHATI0.1%] ( officer use only )
L%C nn : tructior', of a axew buildir*9 s ZONING 02SIGNATIO14 OF PROPERTY
_nd.1ition to :a Uuil.lit,g • PERMITTED PRINCIPAL PERMITTED ACCESSORY
�A1Lumr:.acion to a building `
(rsa Cl ,,4raq..: to . xc � ricr ttimenLion:s )
s PREVIEW REQUIRED - PLANNING BOARD. ZONING L3DARD
C)Lhor work (a -
QcribL-) SITE PLAN REVIEW # APPROVED DATE
-- +r
VARIANCE # APPROVED L1ATE
GROSS ARL:A OV VROPOSZDL ; 'LRUCTURE ry "
1st Floor � i~ sq ft . /'r�GiSd Remarks :
? n d Floor �� s q f t . �7 CDbIPr.L"i'i: 1;4` 'OfQ%gATION I'Xf 5 IlcCp 1lL I CI . ,
a w at
sq f t . Si. .: of pralsurty 140 �ft x /` Sr�._f c !F
other Floors * LxisCinrj lauii.3ir, � ( :: ) yixu 1 ..� 1' 4 X� r Cc .
( not cellar or basumeDcl #
TOTAL FLOOR ARCA,17 01 _sq f t . " k:xizxing DWi1ai1ua (a: ) U:::u
of nuw 1Lructuru 28 ft S:Ialf-t�.__._-
E'uuardation-pier/:;lata/crawl/L�arti[.al,,+�uI.L-' ' 1'ra,��o::ud l�uiluirsg , d.i:;cancc: rraa�r �;�r�ai�ua ty lirtiu
(circle one ) Front yard s rt Roar yard r� 7 ft
Na . of stories (Z "blc:a �-1's blo ncc ) yz Side yards �7 or and Cr
lt&.:ighC ( tirade to ri.dqu ) $- ft . R If on corner , e.;L, rb:ack -from side: scr4 rt
1 f raaidential , no . of [amiiie
No . of rooms ( excluding baths )_ OGCU�' JL-Y 1NFC3P.MAT 1Llf�!
r1o. of btdrooinz:
PRIMARY LrUILL3IlJC
NCI . of k"Chrooms t...-�{]no .Cauu.ly dwelling
iArilrury Sruaeiaxq L:ysvkIuM • r-- ";wo f"L"ly dwelliny
"rylau uf• fuel A US ,� Multiple dwulllny f Number of units
How of firuplacas to tie: in::c.alluci Paxw air nr. occup:siray
Will :a Wood ::Love: ]rr. ir,stallud �"J4 �} "rr"nsir:rrt uccup"gLcy
L'untr"l Air cor,elitiranir,g7� h t7 liuNincrss
BUILDING STYLC, PRIKAARY Sl'RUCTU2C Induscrial
ocher
1car1CLL Canesr,,l.oa ..ry Lc,n calliin ; If .add itiore . rd-,ut will b. `l
s;.sisud ranch r+r:ansic�,r ouyl .::x
sl�lic lvvul Old aty1.: uu,r.1.-. low r
C C[�ct:agv Ocla�Y " ACCL•:SSORY 1AUTLD1I+UC^
L'alans :al l:arr I'owr, House " 13rstachad rJsrtagc/cncr car/ two czar/ c:ar
CIR.CLL: OH14 PLEASE ) ar Actacha.:d garaegu/OAO car/ wn cam ' cur
w ■ ■ r w w w • w . w • + * '+�' w ,r privato storiu.ga building
L: «` TIKATI" D MAF21CrT VALU1 DF or.h+: r
See
INFORMATION W nL1ILPINC SnFCXPTCAT3CINS , Dla TLEVCIZSL SIor? oP •PHIS SElli>w"`C, TOAE C4Ml'LG'!'LO !
Form DPA 10/88 v]
BUILDING i � F.R.MIT APPLICATION CONTINUED -
BUILDING SPECIFICATIONS :
Type of ct >nr,truction , wood frame , fire safe . etc . � = i•- ery� -'
Will any ; econd-hand or ungraded lumber be used? If so , for wha�? rt
Foundation wall material 1�I Thickness
Depth of foundation below grade ( to bottom of footing ) !
Will there be a cellar ?Heated or unheated? Floor sq . footage sq ft
Will thert� be a basement? Vz,,j Will any portion be used as living space?
( If so , what portion? sq . ft . - - Type of use? flo D
Type of rcaof - sloped/flat/shed/other Material of roof A.Cr- ��
Size , wood studs " X� " spacing " o . c . length �-f't !
] aists ( iloor beams ) lst , floor _ "X�" spacings " o . c . span
Joists ( floor beams ) 2nd . floor ;) lox / p nospacing__.L. ..._"o . c . span:i ft .
Overlays ( ceiling beams ) "x " spacing "o . c . span _ft ,
Roof raftr_ rs " X It
spacing o . c , span ft ,
Roof trus5cs (pre-engineered) spacing 21__"` o . c . sparlar, ft .
Exterior wall finish vj Of what material ?
Interior wall finish
if a qaracle is to be attached , describe materials to be used for FIRE SEPARATION : $
" "re dl
Is there t_o be an opening between gara a d dwelling? If so will a Fire-rated
door , enclosure , and self-closing device be provided > i 14es
Will a flLie-lined chimney be installed? Height abovib roof ft .
Depth of chimney foundation below grade ft .
Depth of fireplace he_,ax�th ft , in .
Water supj.aiy Munica_paj 'or private well
SEPTIC SYSTEM Distance from ANY private well ( including adjoining properties pd7 ft .
(A separare application is necessary for any repair or new installation of septic system)
D E C L A R A T 1 O N
`l'o 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 wort shall be complied with, whether specified
or not , and that such work is authorized by the owner.
Signature f 05pc
Owne , w nerfs agent , architect, contractor
In x ,r
SPECIAL CONDITIONS OF THE PERMIT :
F
$y_____� ..................
T
TOWN OF QUERNSBURY
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 :
IV Gross floor area 17Q I
2 . Type of heatuQr?s L ?0 c Ir
3 . Is the building mechanically cooled ?
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_
9 ` ! + q
2 . R value of exterior walls ` 1 /
3 . R value of glazed area
4 . R value of doors kL x 11
5 . R value of floors over unheated spaces� l ----
6 . R value of slab edge insulation •- unheated slab
7 . R value of slab insulation - heated slab �-
$ . R value of heated basement/ cellar walls ( above grade ) r
90 R value of heated basement /cellar walls ( below grade )
10 . Type of insulation - pP�F"fir
c . Controls
1 . Thermostat maximum heat setting
D . Duct Systems_
1 . Is duct system installed in unheated spaces ? YE NO
a . if YES , R value of duct installation p�-fC3
b . R value of duct in other areas
E . Piping Insulation
Y. Size of hot water or cooling carrying agent pipe
2 . R value of pipe insulations
F . Service Water Heating
I . Performance efficiency
2 . Temperature control setting maximum_ IYV
G . For Swimming Pool Only
1 . Maximum heating
Telephone No . r ( C /10
ybtbpl cant ' s signature )
OWN OF QUEENSBURY
CI
APPLICATION FOR
SEPTIC DISPOSAL PERMIT
DATE
LOCATIdN OF PROPERTY FOR INSTALLATION Zb CjrZe.11) I
Owner's Name:.r.5 l Telephone.
Address: 16t - 0ea ria A[ Y
Installer's Name* .-1rih9Q✓� Telephone: 774Z2 -QD, %
Number of bedrooms (residential only)
Total daily flow (compute ( 150 gal per bedroom)
Topography: Circle one: (rjgf Rolling Steep Slope % of Slope
Soil Nature: Circle one: an Loam Clay Other /Depth: Feet
Ground Water: At what depth? Feet
Bedrock or Impervious Material: At what depth? Feet
Percolation test: Circle one: required` required rate min. inch.
Domestic water supply: circle one: unicipalf]Well Other
If domestic water supply is a well
Separation; Water supply from septic absorption feet
PROPOSED SYSTEM: Septic Tanisx( , OOQ ,gal. (minimum size: 1 , 000 gal.)
TILE FIELD : Each Trench feet/Total system length feet
SEEPAGE PIT(S): Number of / Size each feet by jr _feet
Size of stone to be used O./Depth or Thickness feet
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 Queensbury Sanitary Sewage Disposal Ordinance.
SIGNATURE OF RESPONSIBLE PERSON:
DATE: fi c�
OVER
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 ,
the fields and /or drywells
B . No System shall be covered before inspection and approval by the
Building lnspector . Failure to comply with this requirement may
result :in the uncovering of the system by the installer and a fine
of up to $ 250 . 009
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 srappage .
❑ . 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
BUILDING and CODES DEPARTMENT
Bay and Haviland Roads
Queensbury , New York 12804
hemarks :
r �'L-� �f _ :% { �' I �" r --; s Itl ! ,,++yy�.��.�^., i ��-�" :3�t:. 'r7.r:;:'r:ti ;rT-r:•„ -r
:, 1S:sui_ UAW (f.,h11UUYYY)
11 /22 /88
_
PRruuceR 1
THIS CCRTIFICATE IS ISSUED AS A WATTER OF iN6=OA1AATION ONLY AND CONFERS
Charles W . Merriam & Son , l nc . NO RK!HTS UFON THE CEATICICATE HOLDER. THIS CE"TIFWATE DOES NOT AMEND,
EXTEND OR ALTER THE COVERAGE Ar7r Gr3Dk.D UY THE POLICIES BELOW.
701 Union Street , Box lf}38 111 1 Schenectady , NY 12301 b
COlvIPANiES .at t 1.31 DIIV COVERAGE 1
COMPANY
LETTER Commercial Union Insurance Co . r
CGNWANY
,r•,yLJHcD --'---.. _._.. __ -..— LETTER
Forest Woad Homes , Inc . COtA3ANY
c /a Joseph Ammirati LE rTER r
{ 13 Thunder Run CO&WANY 1Y
}11 Gansevoort , NY 12831
GOMPANY
1 LE FTER W=
THIS 1S TO CERTIFY THAT i-GLI CIEB OF Iry StifiAME:E L+STED eiELQW HAVE 6EEN ISjUl=C7Ta -Eli1= If1SVflcD NAMED ABOVE FOR THE POLICY PERIOD INI]iCArIEC?.
NO ISSUED TANLlarlf_: ANY AIN, HEnI SU IsJCE G,i C::unaOITION QE AfiY ti.Q FJ iFI.H.ruT U+i OI'iiil-i QGGi}McN7 YJ17H Ht:2P�ECT TO WHICH THIS CE.kr TjCr1CATE MAY
BE ISSUED OR MAY PtRTAIN=-7HE INSVftANCE Ar=rOHO�ED BY THE POLWICS I�k::CFiic;ED HLr741N IS SUBJECT TO ALL Tilt: TEHn.B, EXCLUSIONS, AND CON01- � v
TIOi3S OF SUCH POLICIES,
CO TYPE OF INSURANCE +"I�L,s:'r iifECl'a'.r Y LIABILITY LIMITS IN -1 OUSANOS F
Lf fs f'G,ICY f+;LJ h,1UEf�l PU:=c1' Exrlltal�urJ _ __ _
L I..E #di.b LG;}yi DAIE J -r."at'vj ..-.... .. _..—_ C-At'�i� AGGFlE GATE -
C5F ERAL LIABILITY --- -- t?[;Cu+�r+€r.rL
GC Y
CUMPREraEN5UE FORM INJURY ¢.
PREMISE5lf}PERgTlOYJS W
.� UNDERGROUND PROPERTY .j
oaMscE
EEXPLOSIONd COLLAPSE HAZFFI7 $ . ' .{
PRODUCTSICOMPLETED OPERATIONS $ ,#
CONTfiACTOAL al & PO Fo $ S
INDEPENDENT CONTRACTORS
BROAD F08h1 PROPERTY DAMAGE -g
PERSONAL INJURY PERSONAL INJURY {
AUTOMOBILE LIABILITY Ii,;UiLi -
ANY AUTO
- IMEH
ALL OWNED AUTOS (PRIV. PASS.j �clr Y C :1
ALL OWfaE.D AUTOS {OTHER THAN)
PRIV. Pi.SS / utri m:Cluer.ri
MIRED AUTOS '
NON-OWNED AUTOS pq MAGIETM $ "e
j
LL GARAGE LIAB,LIFY '' '
a, &LL
PG
. . y CGMtiINED �` I
EXCESS LIABILITY --� m."- -- - -'—"""' -
uMBRELLA FORM bi PC)Ea $ $
OTHER THAN UMBRELLA FORM
WQRPCEws• corinENsarlaN
STArI u rc7RY 6
A AND CJ89HO999649 4 /9 /88 /9 /89 --- � iEACII ACCIDENT;
EMPLOYERS' LIABILITY _^^ --------�— -- `--_— --_ - ---` � _ (DISFALICY LUAtT)
OTHER $ (DISEASE-EAk:ly FNIPLOYEE) :' :
DESCRIPTION OF OPERATkONS/LOCATIONSNEHfCLESISPL-C1AL iT EMS - T ----- -- - - --- --T ""
r : - 'Y ,..
Town of Queensbury SHOULD ANY OF THE ABOVE DESCRIBED POLICIES 13E CANCELLED BEFORE THE EX- ;
Building Dept . PIRATIQl DAl-E THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO
P MAIL I � OAYS WRITTEN NOTICE TO TK- CERTIFICATE HOLOCEI NAMED TO THE �
Que ensbury , NY LEFT, OUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
- OF ANY KIND UPON THE COMPANY, P)SGENTS OR REPRESENTATIVES-
Id FI
§ AU TH UU R a 2 ED EPi=iESENTr_TIVE A�,,.
Brian H . Merriam
4
>r:s c p� 1f.1!i lf IV P -. .
g
s j' 'IS SUe: PATG (fAMiCTQ!'r'Y)
PRODUCER
THIS CECITWICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS
NO RIGHT'S UPON THE CERTIFICATE KoLOER. THIS CERTIFICATE DOES NOT AJWEMp, ? .'?'
EKTENO CIA ALTER THE COVERAGE AFFORDED by THE POLICIE5 l3rcLOO
Avid Insurance AGency , Inc .
425 New Karner Rd . COMPANIES AFFORDING COVERAGE
Albany , NY 12205 ;''
LEER
General Accident Ins . Co ,
COMPANY
INSURED LEI-fEF` The State Ins . Fund ' '
G & C Plumbing & Heating Co . , Inc . COMPANY C
c _ 130 Quail St . LETTEIR
_
Albany , NY 12206 COMPANY LLnk-M
COMPANY
LECrEH
THIS IS TO CELIT&Y THAT POL;Cs E;: O� Iiiu UFi: .. LY:.�7c7 tiELiSW HAVE L.EC,J I�;::,Ucl7 TO Tric Iils1}IT[O N: r.YLY:r AL.OVE FOR THE POLICY PL'.HIOLIIIJO;CATED. �
INOTYaITriSTA1WD,NG ANY iYiutii :.,'....::�:T. Cis ::i;.;.U4-i i.iYJ f.+r xrJ Y' is GlvTe;.,;,: i' U: Y Ol rYcA DOCUMENT W141; "CzS 'EL:'r TO WHiCri THIS CERT"IFiCATE MAY rY
BE ISSU.-O ❑r`I L.,::.Y ?cFiTN;: . 'tnL a,.::L...,.ry Ct_ III,'.-Y.. Aij"U Y,s:isclri is ;;Ut3JLC'f 1 is L L. Tl 1L TE L%4.a;:,. LX C LUS i U iv S, AriU CONQi-
TIONS OF SUCH POLICIES'
TYPE (Dr- YFJSUi=t^.rwrl .-v, I�'Y' rJ Uf..i.i:=rs -+- v+ iti 'Iir< 1Y41 . ii ::�,: :,,.: L,ri GIUTY LIMITS IN 7HOUSNFJp.S L,ae Y Y'J,) Y1 UAlt '-�--
Ai,�:i3r-,G,A rE '
GEIIFR+".L LIA1s,L#TY
�:k.:Cu,iY�i ry i.t a. .
.__.__ ____ ___,. ^'"'"" —, uci,.3,Lv .
��Nsur{Y $ :
A .. _
F'riLd 'J3Ew'vr'f-I..y f�JrJS
EXPL SGSOUrJJ rri[ir€'.
EkPE�iS1UfJ 8 L:iJLLis?:;E N.,�:,,�.;i �^+xt++•-+t � $ I
PHOUL}Cf 1G(i:.rr'L ET ED ON -:..-4' ,_ll
cc:JTP; c Tu L SMP 701251-01 3/ 29/ 88 3/29/89 500 , $ 500 , '.
E , ;1JJErtNUE;. I Jui.TFy;i,:]Uf-:'. I
G NlfinE 5
J .. I380AD FGiiL1 r,-'GPLItTY
PER,`:ONAL IFS..JiiY
PEHSO AL INJURY
AUTOh.OtiILE LY:aFlILITY
X ANY AU f D II,.u4ir r '
$
A WLH �c7:linJ ,
:+LE .,I^J:JEU :.t, COS (YHi V. I• } �.I.x_i �!,•
I r ,fon,:r;
I
k t :� ALL C1w'rfo['U AJ TU:i IPHIV Nr°.S .� ircli %.iGl:ie h?I $
X HIRE[) AUI U5
sii;r<-ovrtr&u a,JrOs BA 0019391 01 3/29/88 3/ 29/89 DAP GF bs I
4
L"wtRL+GE LIni31LIiY
COMBINED 750
+ EXCESS LIABILITY��
0 U1.1bAELLA FDHr.1 ♦31 a pD 7
..". CGINIa.NEL7
OCHER THAN Uf46RELLA FCAIA �:..
WORKERS` COMPENSATION
Y : B AND To Follow from The Stat Ins . Fund 823336-3 � (each accl[)rrlr)
Y s lx` EMPLOYERS' L1A5JLITY (DiSEASF•Y-'ULtCY L[CAII) .i
OTHER .�---m .' 1Li15Li;jl.-EAL:7IFMY'L.UYkE} .` _
OESCRIPTION OF OPGRA71ONS1LOCATiONSfJEH;CLESe S14ECIAL ITEMS -
Plumbing & Heating Contractor . Subject to conditions & exclusions of the policy . rP
" -I
YF` w t~rl" x
Ir Forest Wood Homes SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EX•
13 Thunder Run PIRATIp F DATE THEREOF, THE #£S UINC, COMPANY WILL ENpEAVON - TO v_
MAIL lU DAYS W{iI TTEN NOTICE TO THE CERTIFICATE' HOLDER NAMED TO THE
Gansevoort , NY 12831 LEFT, GUT FA1LuaE TO MAIL SUCH NOlkC SHALL #�,oncc+ N4 OBLIGATION OR L1A8IL1TY
OF ANY Y.iND UFOr1 E COMPANY, I" AGENT5 OR HEPkESEN7A71VES,
AUTHORI2 E'D OFPi3FN ATIVE �a �e r •�
.:',l i`:•r .'e:::,Jl,..ry;;r t . ki '✓ ./ `+C:�-.�C%iL. C� r q Y i
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lId
- -:iYalM:rx. • NAIL
Lii'9Yi1 il�If�IIAiS Wr�..::.'„�:'' .�..�...�.::.'
Lr
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PAODUCEA 12 12 F3a
tTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONE ED.`.
S UPON THE CERTIFICATE HOLDEH, THIS CERTIFICATE DOGS NOT AMEND,
T..,,..�.. R ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOw-
WLse 10 lsailat3ac3 PI COiV1PANiES AFFORDING COVERAGI -.--
aar" a ems. MV* 12a66 i `
�► � yt4oxmmtit'1iC:INSUREE.D �LiDavld kkxkwrd�d tjx*w
RD IG PaqW AX>1C31 Rd. LETTER Q
s
COMPANY "" I
LETTER E I
a.
EN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERrOoIFiprCA
THIS IS TO CERTIFY THAT POLICIES OF INSURANCE LISTED BELOW HAVE BE
TED,MAY
ap
I. f
NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY E:ON7RACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CER7€FICATE I
BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIERIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS, AND CONUI• a
TIONS OF SUCH POLICIES. S DESCRIBED
LO TYPE OF INSURANCE POLICY EFFECTIVE POLICY EXPIkAI ION
:.TR POLICY NUMBER DAIS IM4WEOM) DATE IrAAVCQ"j ALL LIMITS IN THOUSAND'S
GENERAL LIABILITY I
COMMERCIAL GENERAL LIABILITY GENERA. AGGREGAU ,$
PAOOuCT$ C06'IPI OPS ALiiRE GA TE $
CIAIMS MADE OOCCUHI#E NCE
MNER S d OONTRACTOIRS PROTECTIVE PizRSONA, a ADVEA€IS .+.G INJ Uri 1 $
EACH OCCuAAFNCE $
FIRE DAMA44A ZANY ONE FIr+Ei $
AUTOMOBILE LIABILITY rAtIALAL FAI'rh Z5F ,ANY LAM Pt Hs41,. $
11
ANY i UIU CSa
ALI. U1hNE€7 AUTOS $
j
W 1r]r1,r
SCHEDULED ALrTOti
,PLR rEnSDNr $
HIHEa auras emu,^r --
NUr€-OWNEa AUTOS IN,IJRr
1HFH
GAR4GE Lik6iuTY
unrnnc€
CAMACErY j EXCESS LIABILITY _ _
L. .n ,."LJgy .♦ . p ,.1, 9 mi. 1 _ m
OTHER THAN UNIIIAELLA FORM $
!!ll I
WORKERS' COMPENSATION jTATU tOR Y
AND �o,�,,�hy 1 �1 / ,r $ '[} IE :.�r. :,,... i !
` E€.4PLOYERS" LIABILITY C:29959110 .12 .15f &g 12/15/89 $ ��j �� �`'.l �_, 1'I
mamma
OTHER - I-��.. .- - --.
W
r
DESCRIPTION OF OPE RATIONS I LOCATIONS IVEHICLESIRESTRICTlONSISPECIAL ITEMS '-`�"
am-
ma
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFOHE THE Ex
�72ArQuixate PIAATION DATE THEREOF, THE ISSUING COMPANY WILL ENI:IGAVOA TO
milt Wood } omes f jr=0 MAIL 3&AYS WRITTEN NOTICE TO THE CEFTTIFICATE HOLDER NAMED TO Tnl- r f VV
13 Thunder I�Lm LEFT. BUT FAILURE TO MAIL SUCH NOTICE `StiALL IMPOSE 110 00c,IGA I J;. A, s III
GanuevDcMme NY 12831 KJNO yI+ON THi COMPAN'i. , i S,pGcrmil to Ut, ilc_?,.L.St 1, i :. + I
AU IHOAN ED ALt'FiE�e NTATILE Fr r. .f -
nn
/ G•'. lrLf_y-,Y'-y /Q -/ /y_ rv-°i11'' . .✓ "•. ..v ,•s:'_'F. pe.d" f
.,t,ti.,�^N'k"Kt•"�r'w!T` r.L4L 9l.lJ-Gu "'1..../ Q..•'�- rV.- •' LK :'LT• �r :: !
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. . T�! :3v741i1`13?'y�H..'!R,i9ai14FYiX'.-?A-ew' F . . .
MIDDLE DEPARTMENT1INSPECTION AGENCY, INC.
900 Haldddn Iitre:+`�i; plllnyiwobd; N.5. 09i06 .. �;r
ell4 oRtV May 24 , 1989
�ertlfteo that the electrical equipment listed has been exan*lned'aNO .a pproved as being in accordwith the National Electrical Code, applicable governmental, utility and p en ,lies.
Forest Wood Homes r`
Owner: O.Paupar{cy c,Dwel. l..ing I
Single Family � ,:I.... ,
Occupant: Lot 110 Oak Tree Circle ( Hidden ..Hil.ls ) , Kttieen9bu � �WArren Co 13Y
Location-, This oe Icat dovara the.electrYc uipmant and installation inspected this
date. If additional aNuiphnent 'shdr4ld he Introduced or allarations made to
+t (inspection
system this certificate shill ba null and void, and applFcahon for
Equipment: 93 Outlets ; 50 Receptacles ; 23 Fixtures ; 2Qllnspnctlon should 6e submitted prge�p[ly [olhisAgenCy-
A __HH d der of this cortif is ate should prose nt same to ri is property in so ranee carrier
Amp Service , I7 Appliances I agent or Comps ny) a s evidance of cart Micat Ion of a lac tri Cal equipm a n t ap proved
Y as specified.
Forestwood Homes`
-`'
Applicant: HC -O2 , Box 286P ,.x;;.:"'"" r` o 15- 021840
Warrensburg, NY 12885 -
Ferar Hdi "a EL i-0.1 _._ ��._..__.. _.. . _ _
I WN OF QUEENSBURY
BUILDING AND CODES DEPARTMENT
BAY & HAVYLAND ROADS
QUEENSBURY, NEW YORK I2804.
TELEPHONE (518) 792-5832
BUILDING INSPECTOR ' S REPORT
REQUEST FOR SPECTXORECEl/VEII
NAME
LOCATIOlIt�
DATE ERMIT #+ ,�' `-
APPROVED
YES NO
FOOTING/PIERS
MONOLITHIC POUR FORMS
FOUNDATION/DAMP-PROOFING
BACKFILL APPROVAL
ROUGH PLUMBING
FRAMING
ELECTRICAL ROUGH-IN
INSULATION:
FOUNDATION
FLOORS
WALLS
CEILING
FINAL INSPECTION:
CHIMNEY HEIGHT 1.
ROOFING y.
SIDING y
EXTERNAL PORCHESISTEP,t ; !
STAIRS-CLEARANCE & XlErg
PLUMBING FIXTURES/RI;LIEF. VALVE (/
INTERIOR TRIM/PRIVFtY DObRS
FINISHED FLOORS
GARAGE FIREPROOFS G
DOOR CLOSER (S)
SMOKE DETECTORS
FINAL ELECTRICAL NSPECTION
FINAL APPROVAL O CONSTRUCTION
A SIGNED CERTIF CATE OF OCCUPANCY MUST BE
OBTAINED FROM T E BUILDING DEPARTMENT BEFORE
THESE PREMISE'S RE OCCUPIED!
REMARK'S:
INSPECTOR
aavn 0/ Quee" JAttry .
BUILDING and ZONING DEPARTMENT
Bay and Haviland Road, R.D. 1 Sox 98
Queensbury, New York 12801
SEPTIC DISPOSAL_ SYSTEM INSPECTION
NAME
LOCATION67
DATE =��� �� PERMIT NO . 6 / 7
SOIL TYPE - Sand - Loam - Clay -
Percolation Test Required? YES - NO
Percolation rate - Min/Inch
TYPE of SYSTEM:_
Absorpti field , total length
Length of ach trench �? li'
Depth of tr Iiches -
Size of grave' _
SEEPAGE PITS4NUpber of) _
Size- ft.
Gravel size
PIPING : Si
Bldg , to tank
Tank to dist. box
Dist. box to field/F t i
Openings sealed? mytS O Partial
LOCATION/SEPARATAONS :
Foundation to tAnk f t.
Foundation to Absorption ft ,
Absorption to/lot line ft.
Separation o pits ft.
LOCATION OF YSTEM ON PROPERTY (circle one)
Front - Re - Left side - Right side -
CCMMENTS :
A 0
A � � � � �
of c ;r
SYSTEM USE APPROVED YES
Buil g Inspector
0l/86 and vl
TOWQUEENSBURY
BUILDING AND CODES DEPARTMENT
BAY 6 HAVILAND ROADS
QUEENSBURY, NEW YORK 1280k
TELEPHONE (525) 792- 5832
BUILDING INSPECTOR' S REPORT
REQUEST FOR INSPECTION RECEIVED
NAME ,(l G�L� d crrz -
LOCATION / en^ K C e 4f, ,te cq4�'r
DATE / c ..� PERMIT
APPROVED
YES NO
FOOTING/PIERS
MONOLITHIC POUR FORMS
FOUNDATION/DAMP-PROOFING
BA+C'KFILL APPROVAL
ROUGH PLUMBING
FRAMING
ELECTRICAL ROUGH-SN
NSULATION:
FOUNDATION
FLOORS
WALLS
CEILING
FINAL INSPECTION.-
CHIMNEY HEIGHT
ROOFING
SIDING
EXTERNAL PORCHES/STEPn�
STAIRS-CLEARANCE & RAILS
PLUMBING FIXTURES / LIEF VALVE
INTERIOR TRIM/PRIVCY DOORS 1
FINISHED FLOORS d
GARAGE FIREPROOF.NG
DOOR CLOSER (S)
SMOKE DETECTORS '
FINAL ELECTRICAL INSPECTION
FINAL APPROVAL. OP,, CONSTRUCTION
A SIGNED CERTIFICATE OF OCCUPANCY MAST BE
OBTAINED FROM THE BUILDING DEPARTMENT BEFORE
THESE PREMISES ARE OCCUPIED!
REMARKS:
INSPECTOR
TOWN OF QUEENSBURY
BUILDING AND CODES DEPARTMENT
BAY & HAVILAND ROADS
QUEE'NSBURY, NEW YORK 12801
TELEPHONE (5I8) 792-5832
BUILDING INSPECTOR ' S REPORT
REQUEST FOR I SPECTI RECEIVED��
NAME
LOCATION r _
DATE 4 � � PERMIT # 2q m
APPROVED
I r c! I YES NO
•FOOTING/PEERS
r MONOLITHIC POUR FORMS
? FOUNDATrON/DAMP-PROOFING
J BACKFTLL APPROVAL
ROUGH PLUMBING
FRAMING
ELECTRICA ROUGH-IN
INSULATION,;
FOUNDATSCV
FLOORS \\
WALLS
CEILING
FINAL INSPECTS
CHIMNEY HEIGH
ROOFING
SIDING
EXTERNAL PORC S/ EPS
STAIRS-CLEA CE & ILS
PLUMBING FI RES/RE EF VALVE
' INTERIOR M/PRIVACY RS
FINISHED F S
GARAGE FX#.EVff30kXNG
DOOR CLOS R (S)
SMOKE DE TORS
FINAL &LECTRI AL INSPECTION
FINAL APPROVAL OF CONSTRUCTION
A SIGNED CERTIFICATE OF OCCUPANCY MUST BE
OBTAINED FROM THE BUILDING DEPARTMENT .BEFORE
THESE PREMISES ARE OCCUPIED?
REMARKS:
f
J
INSPECTOR
TOWN OF QUEENSBURY
BUILDING AND CODES DEPARTMENT
BAY & HAVILAND ROADS
QUEENSBURYo NEW YORK 12804- ' +"
TELEPHONE (518) 792-5832
BUILDING INSPECTOR ' S REPORT
REQUE T FOR 4TNSPECTXON RECEIVED
NAME
LOCATIO
BATE —cry PERMIT # -
APPROVED
YES NO
FOOTING/PI
MONOLITHIC UR FORMS
FOUNDATION/ P—PROOFING
ILL APP VAL
GH PLUMBIN
RAMINGK NJ
ELECTRICAL ROU —IN
INSULATION:
FOUNDATION
FLOORS
WALLS
CEILING
FINAL INSPECTION.;
CHIMNEY HEIGHT
ROOFING
SIDING
EXTERNAL PORCHES/ST S
STAIRS—CLEARANCE & ILS
PLUMBING FIXTURES/ EF VALVE
INTERIOR TRIM/PRIV CY DOORS
FINISHED FLOORS
GARAGE FIREPROOFI G
DOOR CLOSERS)
SMOKE DETECTORS
FINAL ELECTRICAL NSPECTIO _
.FINAL APPROVAL OF CONSTRUC ON
A SIGNED CERTIF CATE OF OCCU ANCY MUST BE
OBTAINED FROM HE BUILDING D ARTMENT BEFORE
THESE PREMISE ARE OCCUPIED!
REMARKS.-
INSPECTOR
TOWN OF QEENSBLiRY
BUILDING AND CODES DEPARTMENT
HAY & HAVILAND ROADS
QUEENSBURYo NEW YORK I2809-
TELEPHONE (518) 792-5832
BUILDING INSPECTOR ' S REPORT
REQUEST FOR INSPECTION RECEIVED
NAME AX
LOCATION
DA TE �� f PERM T # 7
APPROVED
YES NO
FOOTINGIPIERS
MONOLITHIC POOR FORMS
yIFO UNDA T ZO N/DP-PROOFING
�ACKFILL APPROVAL
ROUGH PLUMBING
FRAMING
ELECTRICAL ROUGhNIN
INSULATION:
FOUNDATION
FLOORS
WALLS
CEILING
FINA L INSPECTION:
CHIMNEY HEIGHT
ROOFING
SIDING
EXTERNAL PORCHE STEPS
STAIRS-CLEARAN & RAI2FVASVE�__f
PLUMBING FIXT RES/RELI
INTERIOR TR (PRIVACY
FINISHED F RS
GARAGE FI PROOFING
DOOR CLOS R (S)
SMOKE DET CTORS
FINAL ELECT CAL INSPECTION
FINAL APPROVAL OF CONSTRUCTION
A SIGNED CERTIFICATE OF OCCUPANCY MUST BE
OBTAINED FROM THE BUILDING DEPARTMENT BEFORE
THESE PREMISES ARE OCCUPIED,I
REMARKS:
INSPECTOR
TOWN OF QUEENSBURY
BUILDING AND CODES DEPARTMENT
BAY & HAVILAND ROADS
QUEEN,S'BURY, NEW YORK I2804-
TELEPHONE (518) 792-58.32
BUILDING INSPECTOR ' S REPORT
REQUEST �FOJR�� SNSPECTION RECEIVED
WANE
LOCATION � / XI+ 9 L%
DATE PERMIT #
APPROVED
YES O
L 60TINGIP MONOLITHRS
IC
FORMS
FOUNDATXO -PROOF ING
BACKFIL
_.._._�
APP AL
ROUGH PLUMBING'
FRAMING
ELECTRICAL ROUGH-
INSULA INSULATION:
FOUNDATION
FLOORS
WALLS
CEILING
FINAL INSPECTION:
CHIMNEY HEIGHT
ROOFING
SIDING
EXTERNAL PORCHES/S PS
STAIRS-CLEARANCE & RAILS
PLUMBING FIXTURES RELIEF VALVE
INTERIOR TRXM/PRI ACY DOORS
FINISHED FLOORS r
GARAGE FIREPROOMNG
DOOR CLOSER (S)
SMOKE DETECTOR.^
FINAL ELECTRICAL. INSPECTION
FINAL APPROVAL OF CONSTRUCTION
A SIGNED CERTIFICATE OF OCCUPANCY MUST BE
OBTAINED FROM THE BUILDING DEPARTMENT BEFORE
THESE PREMISES ARE OCCUPIEDf
REMARKS:
:1 R
INSPECTOR
TOWNOF QUEEN
BUILDBUILD ING AND CODESES DEPARTMENT
BAY & HAVSLAND ROADS
QUEENSBURY, NEW YORK 1280-& 1'
TELEPHONE (5I8) 792-5832
BUILDING INSPECTOR ' S REPORT
REQUEST FOR INSPECTION RECEIVED
NAME
LOCATION
DATE PERMIT #
APPROVED
YES 1VO
4o ?OOTING/PIERS
MONOLITHIC POUR FORMS
FOUNDATIONJDAMP—PROOFING
BACKFTLL APPROVAL
ROUGH PLUMBING
FRAMING
ELECTRICAL R37U
H—TN
INSULATION: pp
FOUNDATION
FLOORS
WALLS
CEILING
FINAL, INSPECTION.
CHIMNEY HEIGHT '
ROOFING
SIDING
EXTERNAL PORCHES/ $PS
STAIRS—CLEARANCE . & IL,S
�:7
PLUMBING FIXTUR#'/R TEF VALVE
INTERIOR TR.IMf,PRSVACC DOORS
FT NTSHED FL09ps
GARAGE FIREPROOFING
DOOR c FTRCTCAL
O
SMOKE DTRS
FINAL ELE INSPECTION'.
FINAL AP12'ROVAL OF CONSTRUCT£
A STONED CERTIFICATE OF OCCUPANCY MUST BE
OBTAINED FROM THE BUILDING DEPARTMENT BEFORE
THESE PREM.ZSES ARE OCCUPTEDI
REMARKS:
j it
G J J
f
4..a
INSPECTOR
r tut Lttoi tiw�;biN 1'V FiMS tb u5) eza- i i ra
APPLICATION FOR ELECTRICAL INSPECTION
PLEASE BEAR DOWN YOU ARE MAKING (4) COPIES
MIDDLE DEPARTMENT INSPECTION AGENCY INC.
National Headquarters a
900 Haddon Ave., Collingswood, N.J. OB108
• ME • Date : 3
City, Town or Township County W QiY-r f fl state
Location/Address 4 /t/R r
' If
Lo ted in Rural Area - Please Attach directions} Pole #
Owner , rmcs-I� � � � iv pf ? ►V(�IBS Permit
Occupied As Building: NeW� OldO
Occupant
Work Area in Building Floor #, etc. ] :
App. foro Wirin [71 Service O or: Ready for Inspection -
Fee Remitted - $ Cash Check ED M.O. Q Make Payable To : M.D. I.A,
Sail 75a loan 1250 15a0 17tvG 2aaa22 5a 2500 2750 3aaa
Number at Rough Wiring Outlets Elect. Heat
Switches
Lighting Amp. Service Surface Unit Dishwasher Range
Receptacles Water Heater Air Conditioner Dryer Pump
Number of Fixtures 'Oven Garbage Disposal Wiring and Controls for Burner
Amp. Receptacles Fractional N.P. Vent Fans
Other Equipment:
MOTORS H.P. 1/2 1/12 1/10 1/8 1/fi 114 1/3 1/2 3/0. 1 IYa 2 3 5 7Vx 14 15 20 25 3O 40 50 75 1D0
Mark Number
of Each Sire
Applicant's
Signature License # Permit #
T/A Utility :
Applicant's Address: #NAME OFFICE LOCATION
(City) (State) Nl . (Zip) l� b' Service Request #
Phone # Electrician :
• DATE RECEIVED; DATE INSPECTED :
Correct Location : Same as Above Q or:
Red Notice Label =
Rough Wiring Outlets Surface Unit Oven
Switches Range 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/a 1/6 1/4 1/3 112 3/4 1 1Nx 2 3 5 71la 10 15 24 25 34 44 50 75 1200
Mark Number
of Each Size
v
patt'iek 3 Dashnaw Elect. Heat Soo 250 taco 1250 IsOa 17, 200o xxsa 2500 7150 3aao
Q�p a iox 3A 12839
. la4i-3473
ELECTSICAL 114SPECTOIR
CERTIFICATIONS USE FOR INITIAL VISIT ONLY NOTIFIED DATE CORRECT FEE PAID
0 RW Progress- Inc. LKD 0 Contractor
0 CFT Violation : Work Comp, C] Inc.
[] L/A Owner CASH 0
LJA Fee CHK #
Due MO #
Q IPA Municipal
INV #
Date : Other Side E:1 Utility Applicant Q
Owner
Cut in Card Q Temp # Date
F-1 Final F1n+A INSPECTORS SIGNATURE
U l< r b d�
'
too ,
l i V
I/ 4 1 II
ApFc'rs ram L"' ' �A,�, �
tars '
De I< 'free ) rc, C
14