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1989-117 r � i CERTIFICATE OF C►CCUPANClAr TOWN OF QUEENSBURY � WARREN COUNTY. NEW YQRK 1 PIELY 31 lq 89 Daft { I This is to certify that work requested to be done as shown by Permit No. has been completed. .� �! This structureS u as a F U i 1� � Qw u l l � i s T [b L Location 1 C*rfter F ca} i ?30 I{ By Order Town Board -TOWN OF QUEENSBURY G 7 l i Director of Bldg. cSc Code Enforcement r BUILDING PERMIT TOWN OF QUEENSBURY 89 - 117 � No. � WARREN COUNTYr NEW YORK < r-� PERMISSION is hereby granted to. Robert Northgard I I� OWNER of property located at p±yis ±on Streetpqpqpqpqp Street, Road or Ave. I r 0 in the Town of Queensbury, To Construct or place a interior Alterations 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 . 7,0V"M:14ER`PSAddress is Same � 0 x 2. CONTRACTOR or SU) LDE R'S Name C . D . F . R . Inc . 3- CONTRACTOR or BUILdER^S Address O 26 Balboa Drive CD Latham r N . Y . n r'r 4- ARCHITECT'S Name t� S. ARCHITECT'S Address r• c� F O 6. TYPE of Construction — (Please indicate by X) [!] r� ( ) Wood Frame { ) Masonry I } Steel fI7 rt 7. PLANS and Specifications No- 418 sq . ft . XX alteration as per permit # 86 - 845rand Xj6pXjiKXjXj§X application . S. Proposed Use Single Family Dwelling rs 25 . 00 $ �_�__„ PERMIT FEE PAID — THIS PERMIT EXPIRES ©ctobeZ 1 19 f (if a longer period is required an application for an extension must be made to the Building and Zoning inspector of the town of Queensbury before the expiration date.) H r Dated at the Town of Queensbury this 2 8th Day of March 1969 � r P r SIGNED BY f � for the Town of Queensbury r Building and Zon I nspector C U I �r �LJEENSI3URY APPI• ICATTON FOR 8UTLPING AN ZONING PT*RhlITTOW V >'ecr ev 5 edl� TOWN OF QUEENSBURY Rev t. RECEIVED 7 }� �Y Fee Fred _ - MAR 2 8 1989 BUILDING AND CODES DITARIIIENT Ante Iebued aAY and IIAVXLAND ROADS RA 2 BOX 9i3 !!�©G. 8a CODE I]E-z ,c � , f7[IEENSBURY, JVEI>r YDj21ti I2B0-1 Per M t No . Uo S� C 'u "= - uc� ! 2 s Tc2 . (518) 792-5832 Ext •2U4 a a a x a w C7J A PERMIT MUST Bq OBTAINED BEFORE L' EGINNING CONSTRUCTION . NO INSPECTIONS � � WILL BE MADE UNTIL APPLICANT HAS RECEIVED A VALID BUILDINC PERMIT . All applicable spaces on this application "lust be completed and the sivt1xture of the a�plieant must Appear * on the reverse si o o this shect * ' 1�e Owner of this property is : � k� ��T ' v5z"RyrC� Nib S propertyC2 ,/ p . O . Address .�( `/ �C r1s TEL .�/�e� +�5 property location ICI ! 4 +� TAX MAP NO . �/ �_/ JC3 leas there been arty split of this property singe October 10 19BB ? yes / n,� > .— Zf yes , planning Board Review is necessary . LOT NO , SUBDIVISION NAME , IF APPLICABLE 'the Person responsible for supervision of work. as regards building Codes is : NAME: P . O . ADDRC £. S �, /,.'T�+r Tel 7� �„� s - taame of builder C^D� F !� ;[ arvc - Address + � - -sue- �. ?.ddress Tel Name of Plumber Tel Name of Mason Address 14ATURC OF PROPOSL'D 6ORK: . 1 ZONING INFORMATION ( orfic+e use on .ly ) conz; cruet iott of a Ilew building W 20NING DESIGNATION OF PROPERTY Addition to :a building PERMITTED PRINCIPAL PERMITTED ACCESSORY %-�4 Al cvr"L iOO to a Luilding ` ` {iIp c11.LrYr2u to wxc : rior rlilncnsi4ns1 REVIEW REQUIRED - PLANNING UOARD ZONING BOARD Ocher work Wescr•i1�u) iv SITEPLAN REVIEW # APPROVED DATE ; VARIANCE # APPROVED DATE GROSS AREA O1' /� VP DY S r " UCTURE Remarks : 1st Floor sq ft * 2 nd Floor sqft . Y COM['LE:'1'1 . I{11'OI:I1h'1'l4N RCQUI"c1:D 111=LC161 . '" Siry of prol,vrty_ Other Floors set ft . L:. "t.infj Uuildill7] ( ::) yx : v l' 1 x�ft . { not cellar or basement TOTAL FLOOR ARE sq ft . a Lx1z;cing bW1l4i"U (4.; l Usv 1_ }tyZZ-.i"I ( t/cm :." ijIe of ntw ::cructur.: ft x ft E'I�ul�d:atian^Hier/slab/crawl/tnarciul/ tiull " Vroposccd building , dlticancu rroul L,rol�urCy line (circle one ) . Franc yard 5" 5 ft !tear yarrd Nv . of :Caries ()kal�ic:.bla �aac1 _ r rt 1 . W Side yards ` {SC Oft and r llvight ( UradQ to ridqu ) S ft . ,� If an c[+rner, ::I. tl�:�ck from side atrur:c / �t' c " l rc:.idi:ntial , no . of families No * of rooms ( excluding b:,th3 ) „ S ' OCCU('ANt:Y •lIHFQf.1HATICN tdas of bodrooms * p,"3'lptY BUILDING - No * of b:at1►room:s I Onr: family dwelling PritwAry hwacilivii sy::c .:m Cl:r-r e G #~ Two family dwelling Typ" of fuol Mult1p1#4 dwelling / Number of units„ No . of flreplacc:x to b:: irxscall�:ri ;e nollt oacup:.Yicy Will :a wain,! =:%:OVa: LV iFiUtalluci7 y't:an::iurlt cscCui�:arlcy Coarttrul Air cojsd1C10ni1+9:' *-N� k3usinuss s au l 40I NiG STYLE, pit! K&*RY SI-RUCTU E . Induscr ial # Ocher 1r.auch CoauQm x r44ryy Lon cabin lx arddiFiOn , wl'Ii►t will u::+z bv? ranch N"nsi..c.,k DL4pl::x " 11�1it lvvvl Old scyle lsuasyalow C"po Cod COtt:ag%. Oc1wr # ACCESSORY BUILDING^ car Colonial !taw '1•owll k]ause ' 1;swta�chad q aruge/onct car/ two C:sr / ( cilr CIRCLE: ONE PLEASE 3 "" �jLActnc had garae2uJoel a: car/ ti c:a _i s w a . a a a a a a ■ "' Nrivaca .coeuge building KhR1Kr44 VA". U "% OF ' - Ocher C ON ::.'1. 1t U C'1' I UN. 3NF•ORMATTON ON t3UTLOTNC SPECTFTCATIONS . ON REVERSE: SIDE OF 'rilTS CV12ET, TO 50 COMPL.E' C01 Form i3PA 20188 v1 BUILDI' N:., 1 • i:RMIT APPLICATION CONTINUED - BUILr3IhlG SPLCIFICATIONS : Type of cc,nstruction , wood frame , fire safe , etc . Will any �ic:cond-hand or ungraded lumber be used? If so , for what ? Foundation wall material Thickness Depth of foundation below grade ( to bottom of footing ) Will there be a cellar? Heated or unheated? Floor sq . footage sq ft Will there be a basement? Will any portion be used as living space ? ( If so , w}Z st portion? sq . ft . - - Type of use? Type of roof - sloped/flat/shed/other Material of roof Size , wood studs " x " spacing "o . c . length ft , *Joists ( floo.r beams ) 1st . floor "X " spacing " o . c . span ft . .joists ( flexor beams ) 2nd . floor "x " spacing "o . c . span ft . Overlays ( ceiling beams ) "x " spacing '"o . cl span ft _ Roof ranters " X " spacing o . c . span ft . Roof trussos: (pre- engineered) spacing "o . c . span ft . Exterior wall finish Of what material ? Interior wall finish If a garago is to be attached , describe materials to be used for FIRE SEPARATION : is theart2 t.0 be an opening between garage and. dwelling? If so will a Fire-rated door , eric.losure , and self-closing device be provided? Will a flue -lined chimney be installed? Height above roof ft . Depth of chimney foundation below grade ft . Depth of fireplace hearth ft . in . Water suppLy - Municipal or private well SEPTIC 'V ;'VILM _ Distance from ANY private well ( including adjoining ,properties t . (A separato application is necessary for any repair or new installation of septic sS tem) D EC LA RAATION 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. Signature y Owner, owner' agent, architect, contrac or SPECIAL CONDITIONS OF THE PERMIT : �[ A� r, .v YZ ,/ot [ I�1 /�r L x_J' ,�-! L _ by --------- --------- ------------- 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 fallowing : 1 . Gross floor area '%+1 2 . Type of heat &4A& C7*ef �5 3 . Is the building mechanically cooled ? / j 4o 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 'treated 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 s . Type of insulation .- Bo Under 16 % Only 1 . R value of roof and floors exposed to bient conditions 2 . R value of exterior walls I;F= I r 3 . R value of glazed area �/lC�%( a 4 . R value of doors ef 5 . R value of floors over unheated spaces A✓/ 6 . R value of slab edge insulation - unheated slab ,/rj '7 . R value of slab insulation - heated slab/ ,-0!9= i� S . R value of heated basement / cellar walls ( above grade ) 9 . R value of heated basement/cellar walls ( below gr e ) 10 . Type of insulation f~ CM Controls 1 . Thermostat maximum heat setting_ ir3 D . Duct Systems 10 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 . Pining insulation 1 . Size of hot water or cooling carrying agent pipe 2 . R value of pipe insulation �T F . Service Water Heating L. 1 . Performance efficiency 2 . Temperature control setting maximum G . For swimming Pool Only 1 . Maximum heating Telephone No . � � ( appl ' cant ' s signature ) ISSUE DATE (MMIDDPYY) or 03.28-"89 PRODUCER THIS CERTIFICATE IS ISSUED 0 AS A MATTER. OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, X R . M. CANTWELL INSURANCE AGENCY EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES SELOW- 80 wolf Road Suite 416 COMPANIES AFFORDING COVERAGE Albany , New York 12205 COMPANY A LETTER A COMPANY LETTER INSURED COMPANY G Capital District Fire Restoration LETTER 26 Balboa Drive COMPANY D Latham, New York. 12110 LETTER COMPANY E LETTER OrA THIS is TO CERTIFY THE NOTWITHSTANDING ANY REQUIREMENT,POLICIES OF EQUIR'EME.NT, TERM ORE CON04TTION OF ANY LISTED BELOW VCONTRAE BEEN CT OR OUED THER (DOCUMENNSURED T MlITH RESPECT MED ABOVE OTO WHICH R THE THISCERTIF CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN i5 SUBJECT TO ALL THE TERMS, EXCLUSIONS, AND CONDI- TIONS OF SUCH POLICIES. POLICY EFFECTIVE POLICY EXPIRATION LIABILITY LIMITS IN THOUSANDS LT TYPE OF INSURANCE POLICY NUMBER GATE nMwDD,'Wf DATE iNI'+ M01%+Y1 JCc uaaE`+CE AGGREGATE LTR BODILY GENERAL LIABILITY INJURY $ INJURY A x COMPREHENSIVE "M 10 MP 362737 04/01 /88 04/01 / 89 X PREMISESlOPERATIONS DAMAGE $ $ UNDERGROUND EXPLOSION & COLLAPSE HAZARD x PROOUCTSICOMPLETED OPERATIONS BI a PD X CONTRACTUAL COMBINED $ 1 , 000 $ 1 , 000 X INDEPENDENT CONTRACTORS BROAD FORM PROPERTY DAMAGE PERSONAL INJURY $ 1 y OOQ PERSONAL INJURY EIDDL� AUTOMOBILE LIABILITY INJUR'r $ .PER xascrr� ANv AUTO AL_ OWNED AUTOS {PRIV PASS 1 �Lr j +uuilr OTHER THAN Il xa aC:;PE tr $ ALL DENIED AUTOS PRIV PASS f PROPfFIHIRED AUTOS IDAMAGE $ ']AMA ^.ON OWNED AUTOS j GARAGE LIABILITY HI $ PO I COMBINED $ i EXCESS LIABILITY 4 BI 3. PD UMBRELLA FORM Ill II COMBINED $ $ OTHER THAN UMBRELLA FORM S7ArJrcaEvv WORKERS' COMPENSATION ! $ 100 ;EACH ACCIDENTi A AND 010 SC 694397880 04/ 01/88 { 04/ Oi /89 $ 500 DISEASE-POLICY �IIVI,T) EMPLOYERS' LIABILITY $ �O'O sDtS:aSE-EACH EMPLOYE£i OTHER DESCRIPTION OF OPERATIONSILOCATIONS/VEHICLESISPECIAL ITEMS _ • SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EX- PIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE Bay at Haviland Road LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY Queensbury , New York 12804 OF ANY KIND UPON THE COMPANY, ITS A ENTS OR REPRESENTATIVES. ALITHORIZ ENT TIVE f J A ' Vi o _ * i ZONING ck BUILDING PERMIT CIIECK LIST 1 . TYPE OF PEM01T REQUESTED A. NEW BUILDING ADDITIO /ALTERATION 11. RESIDENTIAL COMIVIBJICIAL Co SEWAGE DISPOSAL D. DECK/PORCIi DOCK li. OTHIZR 2, BUILDINC PER Al IT APPLICATION COMPLETED & SIGNED — YE �NO A. 6PLOT PLAN (2 E. 13. DING PLANS (2 COPI T'. /,,(,d +L C, a C. M{ R'IUNIS COA11'. CERTIFICATE D► !' V " F01 CONTRACTORS NAMED D, E N E R Y COD IL f7EE PA1 ~� 3. PROPERTY 'INFORMATION � +, 6 W6� ����/S , 1 , IN APPROVED SUBDIVISIO 2. MEET'S DEPTI1, JV1D`1'II do . FT. REQUIREMENTS 3 . PRE—EXISTING , NON—CON • ORRIING LOT, WITI-I PROPER SET BACKS �4. REQUIRED FRONT PUBLIC ROAD 5 . tIAS IIEQuiltED I S'PR T PARKING G , PERMEAI1LE I;EA IS A ATE ��7 . BUILDING ES NOT I? .X ~E " D MAXIMUM I-EEIGIIT IS LOT CONFOR 'IINO TO CUR EN Z G ? YES NO 4. I ROPERTY IS Z ED AS TAX MAP NO. A . IS USE SPECIFICALLY AL OW IN ZONE? YES NO 1 , PERMITTED PRINCIPAL: ERMITTED ACCESSORY? — ra. SITE PLAN REVIEW T PE TYPE II INDICATED STATE REASON (GAUD' E ECTiON ) b. ZONING HOARD REVIEW USE* AREA SIGN INTERPRETATION (CIRCLE ONE) REVIEWED BY DATE "/-{-��.�1 �,, � `"�~ � � � � d�/5-�' 12 +G--�7! /'V'f,�3 ?�w.J`�,,vG► �+. +'r�u/ ►�'�tp�'/1�'r+�' ,".lcr TOWN OF QUEENSBURY BUILDING AND CODES DEPARTMENT SAY & HAVILAND ROADS oil- QUEENSBURY. NEW YO92- S2- TELEPHONE ! 528 )BUILDING INSPECTOR ' S REPORT REQUEST FOR INSPECTION RECEIVED, NAME LOCATION PERMIT � S�� - /•�� DATE Y p � APPROVED YES NO FOOTING/FIER _ MONOLITHIC POU�_F DOPING FQUNL+ATION/I7ROVAL gACKFILL A �`-� ROUGH PLUMB NG FRAMING ELECTRICAL ROUGH-rN INSULATION: FOUNDATION FLOORS R' WALLS RILING AL XNSFECTION : CHIMNEY HEIGHT ROOFING ` SIDING EXTERNAL PORCHES kISTEPS STAIRS�CLEARANCB 6 RAILS��- PLUMBING FIXTU$ES/RELIEF VALVE INTERIOR TRIMAPRIVACYY DOORS FINISHED FLO04RS GARAGE FIRE OOFING DOOR CLOSE S) �-- -� �...... SMOKE ,DETE TOR _�.-- FINAL ELECTVICAL INSPECTION FINAL APP`RQkAL OF CONSTRUCTION (.FC.ERTIFICATE OF OCC BE A SIGNED UPANCY MUST E OBTAINED FROM THE ,BUILDING DEPARTIKENT BEFORE THESE PREMISES ARE OCCUPrED! REMARKS : C'14e ! INSPECTOR ,ON AGENCY, INC. IPAIDDE_E DEPARTMEHLT i SPECT, ios, 2j s soa Ned�oi►i�a riue, ngsmolf�l:Nk k oats, May 27 , 19 89 g�aart _ roved as being in accord w.k'x#lf lCl that ih electrical equipment listed has been exand i�c9 n saes. .`. 1�cable governmental utility h with the National Electrical Cade app ` ,� Dwe•11in Uc+cupancy. t ° _ _ Owner: Mr . Northquaxrd a 1 QccuPan Fame k-iqyThis car hcate GbrBYa t bfeCtrYc be U;pWent and 'd or Ywner itc ps made d 10 ti@Bns'bury �WT&rrEn Ca) pate i1 add�tYcnal equi RiHenx�ah Isa rnlroduced or aYlerationscatio et4 Division St r15 Q stem 7hia catlYt'ic tae null and void. and ePP �ocatiCft: existing sY ;ytofrliaAgency- inspecnon ario uld be suh lnittarlt p roved t} FiXt.ures 1 Holder of to is cartIficafe should ant same to electrical tricalad insurance carrier 1$ Ou't.let: s , ' , f10 R.eCEt7 tr7�C.j.eS � � � � ' (agent or ComPan as evl �e. . ertHicaiion of electrieal equlP�'nent approved Equipment: as spearerd d. .• Northern LigliEa"xE.leatric :: t : NO 15_022613 Road F • APPrrcarrt: 195-7 Weeks Glens Falls , NY , i Foaas No. 703 EL I-"­ v ,�y1�Vv '-- ARMI IVAIDDLE DEPpFiTlllAl ° ON AGEN Yr INC. 1 �� soa _�--�- Cato March 201, 1989 approved as being in accord eCtlf lC� ' ga�j quip rent listed has been ar � es. ,��ppli,cable governmental, utilityy an d that e• �+ with the National Elect r it Paul Morthgn a 1� p+q � r,y� y,ipmen7 and inslalla7ion indpeCled 5^Is Qwner: Same ` , ` e u -} gtrtil�Cale be inUO40eed or alteratjvne made W (7CCLtparlt' u e W date 51 add4tlona! u�nk µ bo n411 and vDid, and apPlin°flan 'or l}i V i s ion St • existing system tn1 �c • Local on, fly 50 this his pr . inapacSNon should Sib r rt insurance Carrier eriHicat ion al eiactricaY eq uI Pment aPPr nvetl Se � �... may . ark f 1 0� Bolder o! om ce 5l este s 1d ant same 5o rife pro" „'.s R� Ea• "`1`rgent ar comP�nY) ss'svl Equipment: ���} P as specified ;: 4 lectr [] lc , _ w; Northern Ligh N . 15-02131+7 Weeks Road mod,Applicant: NY Glens Falls , 128 Foyer No- TW EL 143 TOWN OF QUEENSBURY BUILDING AND CODES DEPARTMENT BAY ,& HAVILAND ROADS QUEENSBURY, NEW YORK 1280gq TELEPHONE ( 538) 792-5832 BUILDING INSPECTOR' S REPORT REQUEST FOR INSPECTION RECEIVED NAME LOCATION ~ DATE " +Y ' PERMIT # I+ APPROVED YES NO FOOTING/PIERS MONOLITHIC POUR FORMS FOUNDATION/DAMP-PROOFING BACKFILL AFVROVAL ROUGH PLUMBING FRAMING ELECTRICAL ROUSH-IN INSULATION: FOUNDATION FLOORS WALLS , y. CEILING FINAL INSPECTION: ` CHIMNEY HEIGHT ROOFING SIDING EXTERNAL PORCH /STEPS `4: -- STAIRS-CLEARA E & RAILSw- PLUMBING FIX RES/RELIEF ' VALVE --- INTERIOR TR JPRIVACY DOOA6 FINISHED F ORS GARAGE FT PROOFING DOOR CLOS R (S) SMOKE DE ECTORS FINAL ELE _ ICAL INSPECTION FINAL APP OVAL OF CONSTRUCTION_ A SIGNED CERTIFICATE OF OCCUPANCY MUST BE OBTAINED FROM THE BUILDING DEPARTMENT BEFORE THESE PREMISES ARE OCCUPIED ' REMARKS : R r INSPECTOR YOU ARE HEREBY REQUESTED TO INSPECT AND ISSUE CERTIFICATES FOR THE FOLLOWING ELECTRICAL EQUIPMENT TO BE INSTALLED BY THE UNDERSIGNED TEMP. # DATE CITY OB VIL y.-- 1'OYYNSHIP OOUNTY STREET AND OR ROAD POLE NUMBER j : ✓ � 2: i % 'J t BETWEEN WL Two CF K EC dO55 STREETS is PREMBES LOOKED? SinoN BLOCK .�/' LOT/ IN' OCCUPANT'S NAME SUIL DING OCCUPANCY OWNER'S NAME AND ADDRESS HOME TELEPHONE NV 6ER CURRENT SUPPLIED BY y + e C' FROM THEIR �y ,6 OFFICE f G I KrOIRK TELEP E NUM R- �� BUILDING IS /!y` Ll �I/I+J` +j }}��// '/� +l►'. Je NEW ❑I OLD NARK IS NEW.L/IJI. ADWIGNAL ❑ DEFEM REMOVED ❑ LIST BELOW ALL EQUIPMENT WHICH YOU INSTALLED NUMBER OF OUTLETS No. of Fixtures a MOTORS HEATERS BRANCH OFFICE USE Loea- Lamp Receptacles CIRCUITS ONLY Lion Side Am hnt HP %Aftm R.W.G. Ceiling wan Rewp'le Swl" Pendant Bracket NO. Type Each Na Each No- Gauge INSSPE nON OUT- SIDE SUB FL4SE BASE- MENT tsr FL. 2nd FL. 3rd FL. REMARFCF' LIST OTHER ELECTR{CAL DEVICES NOT SET FORTH ABOVE' THIS APPLICATION IS INTENDED TO COVER THE ABOVE-LISTED EQUIPMENT TO BE INSPECTED, BUT IF AT TIME OF INSPECTION. THERE IS FOUND ADDITIONAL EQUIPMENT NOT ABOVE LUSTED. YOU ARE AUTHORIZED TO MAKE THE INSPECTION AND ADJUST THE FEE TO COVER THE ADDITIONAL EQUIPMENT, AS PROVIDED BY THE APPLICANT SIZE OF MMISIS FEEDERS ELECTRIC SIGN SAAMPS TOTAL AWQTS CHARACTER OP WORK ❑ E%POSED GAS TUBE SIGMTRAN SFORMERS OF 1Y. ❑ CGNCF.ALEO DNE L K TO BE STARRED DATE COMPLETED SIZE OF SIGN INUMBERI CAPACITY SEWICE ENTERS BUILDING MANUFACTURER OF SIGN ❑ OVERHEAD ❑ UNDERGRDIND DATE INSPECTx N REOUESTED ON (OR AS NEAR AS POSSIBLE) MUST ENTER AAPPLIONlil $ IDEMIFICK"ON NUM ra ►- I I . I f l I I AVOID DELAYGIVING FULL ANO RATE MWGRMATION. AIL S. CES BE FILLED IN OR APPLICATION MAY BE RETURNED. PRINT NAME AND ADDRESS NAM E�O_F APPLICANT DATE OF AP { ,�grTION SHaMATugE OF APPLICANT { ST ET ADDRE TELEPHONE O- C � .a 4 5-- .7 CITY OR POST OFFICE ZIP CODE LICENSE NO WHEN APPLICABLE G> ❑ 85 Jahn Street ❑ 41 SWe Street ❑ 584 Delaware Avenue ❑ 217 take Avenue El202 Arterial Road LO. NEW YORK, NY 10038 ALBANY, NY 12207 BUFFA NV 14202 I ROCHESTER, NY 14608 SYRACUSE, NY 132W THE NEW YORRK BOARD OF FIRE UNDERWRITERS