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1989-307 ._ . '"� °:p'"R'K: >"�."!�_:" "'r.n.'�R}+-'FPj-t.�v-d;-- •yoSn, cxY- i"St *'� : . I T CERTINC. OF '( CLJ3A.NCOMNe"Yr TOWN OF QUEENSBURY WARREN COUNTY, NEW YORK i pate Septpmh r 13 14 $� I This is to certify that work requested to be done as shown by Permit No, 89-307 1 leas been completed. This structure tmy be occupied as a Single Fami 1 ©reel l i ng - p`j> Pickle li Road f Grant Acres ] Location .i_1..], I owner 1 I By Order Town Board i j TOWN OF QUEENSBURY 1 k Director of Bldg. & Code Enforcement I F BUILDING PERMIT TOWN OF QUEENSBURY -� No. go_ Ana 0 WARREN COUNTY, NEW YORKt. 42, PERMISSION is hereby granted to Don Barbara Manaher OWNER of property located at Lot #1 PICKLE HILL ROAD Street, Road or Ave. in the Town of Queensbury, To Construct or place a SINGLE FAMILY DKELLING 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. OWNER'S Address is 10 PINE STREET rr W. GLENS FALLS ,N _ Y . 12801 2. CONTRACTOR or Bill LDE R'S Name C9 SELF 3. CONTRACTOR or BUILDER 'S Address n�E SAID 4. ARCHITECT'S Name r C 5. ARCHITECT'S Address t C'] S. TYPE of Construction — (Please indicate by XI ITS S XX I wood Frame I I Masonry I I Steal ( I r 7, PLANS and Specifications C No. 36 ' x 69 ' Single family dwelling as per plot plan , specifications , a and application , including septic , drive under garage , and driveway. 8, Proposed Use SINGLE FAMILY DWELLING COO $ 269 . 00 PERMIT FEE PAID — THIS PERMIT EXPIRES December 1 19 89 IIf a longer period is required an application for an extension must be made to the R u i Id ing and Zoning inspector of the G town of Queensbury before the expiration date.) rm -r Dated at the Town of Queensbu s 16th Cray of May _1989 SIGNED BY for the Town of Queensbury C Building Zoning Inspector rrr r C TOWN OF QUEENSBURY APPI. TCATTON FOR BUILDING AND 70NTN0 PERNt1T ` re - FeC TOWN OF OUEENSBURY ,;• ev izwed RECEIVED Fee paid t 9 � MAY 12 1989 1%)UILDINC AID CODES u11'ARTtT2%,r ' (late Ieaued BLDG, COME DEPT. 1AY and ffAVrL..7ND ROADS RD 1 B02C 98 pUEENSBURY', NEIV YDR,K 12804 Pe11.m.�.t No . � -��-7 _ Tel . ( 518 ) 792-5832 Ext 204 tie r Mt w r R r 1t t w * 11 r r ♦ * . r r . r r . w w . w w w A JuC-IMIT MUST D13 OBTAIPdEll BEFORE EECINHING CONSTRUCTION . NO INSPUCT16NS WILL BE AIADt UNTIL APPLICANT HAS RECEIVED A VALTD BL' ILDINC PERMIT . All applicable spaces on this application must be completed and the s must appear an the reverse sick OI thissheet -iounture of the applicant *,,/ !' !Ze owner of this proPerty is P . O . Address TEL . i' raperty location �r1 `. 'PAX MAP NO . / tiers there been any split of this prop since October 1 , yes n, if yes . Planning Board Review is necessary . SUBDIVISION NAME , it APPLICABLE _ t� I' a V7 +�C e" :s LOT Nl3 . •!• he person responsible for supervision of work as regards Building Cod/es i Pr 11 NAME F . Q . ADDRESS TEL . NO . � ' � y rr7.�. ✓ v �s�:l ddress /,_t> .i � �v/ tz Tel �5+� [Jame of builder Tel r4ame of Plumber T.ddress Name of Mason f sy� Addros5� � /�'.fsc... -v"� dl Tel 42"r- �r` ` 14ATURE OF PROPOSED 6ORh. . 20N I NC; I N 1 O IRblAT I ON ( 0. Fi c e use On 1 V ) % Con.a: cYuctlC7n 4 € �,. stew building . ;CONING DESIGNATION OF PROPERTY Addition to :a building + PERMITTED PRINCIPAL PERMITTED ACCESSORY �Alt.: ration to :r Iuilding REVIEW REQUIRED - PLANNING BOARD ZONING BOARD + Oto cik.kngu to uxc . rior aimonsions ) Ocltt4tr wort: (00k criLtt ) SITE PLAN REVIEW !! APPROVED DATE VARIANCE APPROVED DATE GKOSS ARLA O!' PF( OPOSGD� S 'rhUCTURE .. !! 1st floor f (2 5 �6 sq ft . Remarks : 2 nd r loor sq f t . COctC' LL`'!'t IN!'Ol:MA'i'1ON le.U: ,)Ull(E0 1A2LU%J * ' Size Of proL,urty � 7 � ft % ��_�ft . Other Floors /1 'f sq ft . Licistiitx,! L�uil.li„�] ( « ) Si : u_ % re . ( not cellar . r b � s �.. rnent )3 . TOTAL FLOOR AR 'EA1 ql/R sq f t . r E xi� ting l�uil.liny ( : ) U :�aa or new ltructur.: :76 _f t }: & �r t ' t uts, tdatian-pier/ slat,/crawl/L�arcial C : VXopoz:ca building , di:: cancu g sine ( circle onc: ) Front yards ft Rear yard / Z cam' ft Noa of storie. (h:al.>it:able spaCc ) Sid4 yard:; C;? Cc and + it �, tluight ( grade to ridq %.: ) ? <1 € t • It on corner . ;;C Cb:aCk Srarn side ;tr+.c c:2 je t If rk:sidencial , no * of familial / Noo of roa n ( ex+cluding b"thal OCC(JFANl:Y iMFd!'.lM7Ilxf LIO , of budroom.y .�' ' PRIMARY rrSlILDIN[. - No . of b chrootua: + , * �onc fanaly dwelling vrim;Lry llu,atitkxJ yy ; Lvut� > a. a ' yrr � two fau►ily dwut] liny orypQ Uf of tanits�� No . of fireialace:: to LL: ira;:called / Verm&mQnt occuVult CY WL. 11 :a wus,d a;tciwr L� inUt:allutl? lxun. iuskt oL:culs:ancy Caancr.kl Air co,ktA.LtionxJtg :' Le ; """muss UU I LDI NG STYLE, PRIMARY STRL)CTuRE . Indusurial Ocher 1:.4tkclt opt►:+ulsc.r.+x LQa c"- Uln �` if .addition , wl,.at will uua bia7 I:.aiwu[! ranch Mansi"k Dul+lux ' ulalit 1vVQI Old atyl.2 1uu,ky.alow C:.Pu Cod Cott"q*a Ockwr ' ACCESSORY iAUILDING- CG1Qrli .al 1Cow 1'crwii House r DQcachaa cj "rikgo/ana cur/ CVO car/ car ( CIRCLE OCl li PLEASE 3 Aczz*cht,a U"ria CJuf0j'a: car/ two C"rf C" Ln storage building .— �. rzMA`Lt: D MAR1trT VALUE OF Ocher ! sJv 4/!V17Y,f� G.-✓ l7 r CtN �:•rFCUC'rxCaN ), � � � a d • rrsJATION oN puYLDiNC SPTCIi' rCATIONS . ON REVERSE: SIDE- OF TLI. S SF!eET, TO be CO!lPLC` UD ! DPA 10/8e V1 BUILDING PERMIT APPLICATION CONTINUED - BUILDING SPECIFICATIONS : Type of construction , wood frame , fire safe , etc . 4ze.; 42 � Will any second-hand or ungraded lumber be used? If so , for what ? Foundation wall material „/ ot, e�w. Thickness Depth of foundation below grade ( to bottom of footing ) r Will there be a cellar ? Heated or unheated? Floor sq . footage sq ft Will there be a kaasement? Will any portion be used as living space ? ( If so , what portion? sq . ft . - - Type of use? Type of roof - slopo/flat/shed/other Material of roof Size , wood studs X r rr '� spacing" o . c . length ft . .foists ( floor beams ) 1st . floor �; INX ..Zoo, spacing ,0/ib T'"o .`C . span /Z ft . Joists ( floor beams ) 2nd . floor -y !" x z, tospacings'"o . c . span Noe ft . Overlays ( ceiling bea ) , 7 "X��." acing_ / "Cs , c span. �Z1. Roof rafters x "X 2 spacing_ f �.�aa , c . span Or"p ft . Roof trusses gineered) spacing " o , e , span ft . Exterior wall finish_ y( ., �'f o,",�Of what material ? Interior wall finish if a garage is to be attached , 'describe materials to be used for EPARATION : Is there to be an opening between garage and d elling? ,S f so will Fire rated door , enclosure , and self-elasing device be provided? �f _5^ Will a flue- lined chimney be installed? ,*-J Height above Hof 7 ft . � Depth of chimney foundation below grade ft , Depth of fireplace hearth ft . Water supply - Municipal or private well , �'r v;• /G a SEPTIC SYSTEM _ Distance from ANY private 11 ( tncluding adjoining properties � / p' ft . (A separate application is necessary for any repair or new installation of septic system ) DEC LA RATION 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. SignaturefV Own r, owner's agent chi ect, contracto - z Not SPECIAL CONDITIONS OF THE PERMIT : ay_ _____________________ 3 J'OWN OF Q UEENSB URY ..�, APPLDCATION FOR SEPTIC DISPOSAL PERMIT DATE LOCATION OF PROPERTY FOR INS/I'7'ALLATICIN Owner's Name: Po - ,1 ,41J Telephone: Address: S i Installer's Name: 4-74e0041a1d [ mil h' '✓{/ ,��/� Telephone: Number of bedrooms (residential only) Total daily flow (compute Cd 150 gal per bedroom) ' Jr Topography: Circle oneeSFlat Rolling Steep Slope 06 of Sloperoil Nature: Circle one: Loam Clay Other /Depth : Feet Ground Water : At what depth ? Feet Bedrock or Impervious Material: At what depth ? Feet s 5 Percolation test: Circle one: not~required required rate min . inch. Domestic water supply: circle one: Municipal Well Other If domestic water supply is a well: Separation: Water supply from septic absorption J 3 _ _ _ feet PROPOSED SYSTEM : Septic Tank Ir 40 L0 0 gal. ( minimum size: 1 , 000 gal. ) TILE FIELD: Each Trench 5 6 feet/Total system length feet SEEPAGE PIT(S) : Number of / Size each feet by feet Size of stone to be used # /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 Queens& Sanitary Sewage Disposal Ordinance. SIGNATURE OF RESPONSIBLE PERSON: DATE : OVER sc tic S scam Inspections : A , J%" applications for septic system .installation , alteration or repair , as required by the. Town of Queensbury Sanitary Sewage Ordinance , skull b� submic-ted CO the Building Department at least 24 hours before start of cOnsrructiOrn and shall include a plot plan showing : 1 . ) the proposed location of the s } stem 2 . } location and distance to lot lines 3 . ) location anti distance to strucrures 4 . ) location and distance to any water supply 5 . ) size and diriensions of all tanks , distribution boxes , file fields and /or drywells ii . Nu yyscem shall be covered before inspection and approval by the 1Suilding Iaspuctar . Failure to comply with this requirement may r � ,sult in the uncovering of the systcni by the installer and a fine of up to $ ? 50 . 00 C , An approved copy of the plot plan shall be available on the construction site . Failure to produce said plot plan at time of inspection may result in an immediate worm stoppage . D . Should unforeseen problems during construction prevent proper installa— tion , alteration or repair of an approved system , a new proposal must 1ju submirted to the Queensbury Building Department before further con -:; rruccion . Town of Queensbury BUILDING and CODES DEPARTMENT Bay and Haviland Roads Queensbury , New York 12804 fi4Euarks : , 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 a� ! 7 elm 2 . Type of heat FBd�d doU .L�/C�� [ gee Z 3 . Is the building mechanically cooled ? 4 . Percentage of area of windows and doors % t + 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 heatedoil? YES NO a . R value of insulation 51 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 ' 4 . R value of doors 5 . R value of floors over unheated spaces 6 , R value of slab edge insulation - unheated slab� 1` _ 7 . R value of slab insulation - heated slab a . R value of heated basement/ cellar walls ( above grade ) _ 9 . R value of heated basement / cellar walls ( bel�o-w� /grade ) 10 . Type of insulation .��.r �,r C , Controls 1 . Thermostat maximum heat setting ? ram D , Duct Systems 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 iF 1 . Size of hot water or cooling carrying agent pipe 2 , R value of pipe insulation F _ Service Water Heating l . Performance efficiency dq/77 ft' '� �! 4 S .'� + /rs�.•,. a �'+'�/ W a � 2 . Temperature control setting maximum ( u, cp G . For Swimming Pool only, 1 . Maximum heating Telephone No . ( appl i46an ' s signature 1 TOWN OF QUEENSBUR'Y ���� BUILDING AND CODES DEPARTMENT BAY & HAVILAND ROADS QUEENSBURY. NEW YOY9Z_583 " TELEPHONE t B.biLDING INSPECTOR' S REPORT REQUEST FOR INSPECTION RECEIVED = L NAME LOCATION IT DATE _ PERM c� APPROVED YES NO FOOTINGIPTERS FORMS MONOLITHIC POU PROOFING �— FOUNDAT.TON/DAMP A, BACKFILL APPROVA)� ROUGH PLUMBING ~r FRAMING ELECTRICAL ROUGH INSULATION: FOUNDATION FLOORS WALLS FCEILING INAL INSPECTION: - C1gIMNEY HEIGHT ROOFING SIDING EXTERNAL PORCHESIST PS {' ---�--- STAIRS-CLEARANCE & 40AILF VALVE PLUMBING FIXTURESI AELXE INTERIOR TRIMIPRI Cy DO ?RS FINISHED FLOORS - GARAGE FIREPROOF NG DOOR CLOSERS! SMOKE DETECTORS FINAL ELECTRICAL INSPECTION FINAL APPROVAL or Ct]NSTRUCTIO-rT ,� A SIGNED CERTIFICATE OF OCCUPAN MUST RE THE BUILDING DEEPARTMENT BEFORE OBTAINED FROM THESE PREMISE ARE 0CCi7PIEDd REMARKS : i Ja*XN;5PTCO)R THE NEW YORK BOARD OF FIRE UNDERWRITERS ,. BUREAU OF ELECTRICITY 41 STATE STRE ET, ALB ANY. NEW PORK 12207 r ' . . Application No. on file ; , ! S i . THIS CERTIFIES THAT ; 1 i. ', l ; d ". only the electrical equipment as described below and inter by the applicant na+ned on the above application number in the preasiees of .:f '1 ' ?! i .il: E ki I l i ' ? [ I k ". ? € ' 1 . in the following location, 0 Basement 0, Oat Fl. Q Znd Ff. 1: .Section Bieck Lot i was examined on 1 I ' ll ' Jig ) i - k " ' ..` and found to be in compliance with the requirements of thia Board. PIXTURE O=P'tACLES SWITCHES FIXTURES RANCM CoOKINo DECKS OVENS DISH WASHERS RXHAiPST FANS OUTLETS INCANOE5CENT FLUORESCENT OTHER AMT, K. W. AMT. K. W. AMT. K.W. AMT. K- W- AMT. M V DRYERS FURNACE MOTORS RITUOE APPLIANCE PONDERS ISPOCIAL"CPT TIME CLOCKS WU UNIT HEAMOS MMT"MTLl'T DUAMGRS AMT. K. W. OIL H. P. GAS H. P, MAT. NO. A. W. O. AMT. AMP- MST. AMPS, TRANS. MAT. m. P. SYSTEMS AMT. WATTS NO- Of POET' SERVICE DISCONNECT No. of S E R V I CPASTER E AMT. AMP. T'/PF jIP 1 J' 35M 1 jr 9W 3 / 3W S X 4W No' OPEC CCU+D. {1F CC CC* Nok Gf Ni.SEG OF,HWFLEG NO. OF NEUTRALS OF NWELI RAL OTHE! APPARATUS: _ s' ! I ; h + r . _ BRANCH MANAGER Per _ This certificate must not be altered in any man"r; return to the office of the Board if incorrect. Inspectors may be identified by their credentials. COPY FOR BUILDING DEPARTMENT. THIS COPY OF CERTIFICATE MUST NOT BE ALTERED IN ANY MANNER. TOWN OF gUEENSBURY ,BUILDING AND CODES DEPARTMENT .BAY 6 HAVILAND YRK I28d7g- OADS TELEPHONE SE I QU+EENSBURYr W ) 792-St332 BUILDING INSPECTOR' S REPORT REQUEST FOR INSPECTION RECEIVED NAME LOCATION F � PERMIT # —�—� DATE �7 � r T �---` APPROVED YES NO FOOTINGIPIE MONOLITHIC PO R ro —PROOFING BACKFILL APPRO L�----- ROUGH PLUMBING FRAMING ELECTRICAL ROUGH — VINSULATION: FOUNDATION FLOORS WALLS CEILING FINAL INSPECTION : CHIMNEY HEIGHT ROOFING SIDING EXTERNAL PORCHES STEPS STAIRS—CLEARANC RAILS SIRELIEF VA' E__ -- PLUMBING FIXTU INTERIOR TRIMI ,RIVACY DOORS FINISHED FLOOR GARAGE FIREPR FING DOOR CLOSERCS SMOKE DETECT O SINSPECTION FINAL ELECTRICA FINAL APPROVAL F CONSTRUCTION A ,SIGNED CERTIF ATE OF OCCUPANCY NTJST BE OBTAINED TAI ED FROM T AREOCCUPIED ! ILDIGEPARTMENT BEFORE ESE REMARKS : — -- �� INSPECTOR TOWN OF QUEENSBURY BUILDING AND CODES DEPARTMENT BAY & HAVILAND ROADS QUEENSBURY, NEW YORK 3280& TELEPHONE (518) 792-58.32 BUILDING INSPECTOR' S REPORT REQUEST FOR INSPECTION RECEIVED �7 NAME LOCATION DATE �7 PERMIT #u S` ? ` '46: APPROVED YES NO FOOTING/PIERS MONOLITHIC FOUR FORMS FOUNDATIONIDAMP-PROOFING BACKFILL APPROVAL L/ROUGH PLUMBING . PRAMI NG ELECTRICAL .ROUGH-IN INSULATION: FOUNDATIO FLOORS WALLS CEILING FINAL INSPECTI CHIMNEY HEIGH f ROOFING SIDING EXTERNAL PORCHES/ EPS STAIRS-CLEARANCE & I PLUMBING FIXTURES/R I F VALVE INTERIOR TRIMJPRIVAC C)ORS FINISHED FLOORS _ GARAGE FIREPROOFING_ _ DOOR CLOSER (S) SMOKE DETECTORS FINAL ELECTRICAL IN ECTIO FINAL APPROVAL OF ONSTRUCT ON A SIGNED CERTI CATE OF OCCUP Cy MUST BE OBTAINED FROM HE BUILDING DEP TMENT BEFORE THESE PREMI ARE OCCUPIED ! REMARKS: r , 2NS�`GTOR - .....!Dorn D� �rs�+en36urre�r BUILDING and ZONING DEPARTMENT Bay and Haviiand Road, R. D. i Box 98 Oueensbury, New York 12801 SEPTIC DISPOSAL SYSTEMS INSPECTION oe NAMEr rjti;7 LOCAT I .Z.[.¢./ DATE PEWIT NO,___ "f- SOIL TYPE - Sa d - Loam - Clay - Percolation Te t Required? YES - NO Percolation rat - Min/Inch _ TYPE of SYSTEM: ) Absorption field ,A total erb§th Length of each tr ch . Depth of trenche Size of gravel SEEPAGE PITS r Size- ft. rav,e PIPING : A T pe Bldg * to tank. C, Tank to dlst . box y __ Dist. 'box to f m 19Openings sealed? aO Partial LOCAITIC}N/SEPARA IONS : ��- Foundation to ank ft. Foundation to bsorption �t . Absorption to lot line + Separation o pits LO7C TION YSTEM ON PROPERTY (circle one ) Front ea Left side - Right side - COMMENTS : i SYSTEM USE APPROVED YES. Buildl r�spec or 01/86 and vl TOWN OF QUEENSBURY BUILDING AND CODES DEPARTMENT BAY & HAVILAND ROADS QUEENSBURY, NEW PORK 1280& TELEPHONE (518) 792-5832 BUILDING INSPECTOR ' S REPORT REQUEST FOR INSPECTION RECEIVED NAME LOCAT SO,7N DATE `V<E PERMIT ## rS `� 3✓ ! APPROVER YES INO FOOTING/PIERS MONOLITHIC POUR FORMS Soof�OUNDATIONfDAMP—PROOFING j,4ACKFILL APPROVAL ROUb.Q PLUMBING FRAMING ELECTR AL ROUGH—IN INSULAT N: FOUNDAT N FLOORS WALLS CEILING FSNAZ INSPECTI CHIMNEY HEIGH r ROOFING SIDING EXTERNAL PORCHES/ S STAIRS—CLEARANCE & ILS PLUMBING FIXTURES R IEF VALVE INTERIOR TRIM/P VAC OORS FINISHED FLOOR GARAGE FIREPR FIND - DOOR CLOSER (S SMOKE DETEC RS FINAL ELECTRI AL INSPECTION FINAL APPROV L OF CONSTRUCTIO EE E f A SIGNED CERTIFICATE OF OCCUPANCY T BE OBTAINED FROM THE BUIL.D£NG DEPARTMENT BEFORE THESE PREMISES ARE OCCUPIED! .REMARKS: aT NSPECVOIR TOWN OF QUEENSBURY BUILDING AND CODES DEPARTMENT � , y BAY & HAVILAND ROADS ///i�' QUEENSBURY, NEW YORK 1.280k TELEPHONE (518) 792-5832 BUILDING INSPECTOR ' S REPORT REQUEST FOR INSPECTION RECEIVED NAME F LOCATION £7T,f/;r' Af DATE -=`�r'�' PERMIT # APPROVED YES FOOTING/PIERS MONOLITHIC POUR FORMS FOUNDATION/DAMP-PROOFING BACKFILL APPROVAL ROUGH PLUMBING FRAMING ELECTRICAL ROU H-IN INSULATION: FOUNDATION 1 FLOORS WALLS CEILING FINAL INSPECTION: CHIMNEY HEIGHT ROOFING SIDING EXTERNAL PORCH /S PS STAIRS-CLEARA E & ILS PLUMBING FIX RES/RE IEF VALVE INTERIOR TR /PRIVAC DOORS FINISHED F ORS GARAGE FI PROOFING DOOR CLOS R (S) SMOKE DE ECTORS FINAL ELEC ICAL INSPECTIO FINAL APP OVAL OF CONSTRUCTION A SIGNED (ZERTIFICATE OF OCCUPANCY MUST BE OBTAINED FROM THE BUILDING DEPARTMENT BEFORE THESE PREMISES ARE OCCUPIED ?' REMARKS: INSPECTOR YOU ARE HEREBY REQUESTED TO INSPECT AND ISSUE CERTIFICATES OR THE FOLLOWING ELECTRICAL 'EQUIPMENT TO BE INSTALLED BY i THE UNDERSIGNED Q.• —� TEMP. K DATE ,�S CITY OA VILLAGE .may IOWNSHIP COUNTY or S -ex STREET AND NO OR F*:bAD POL VMBER /'rnp 7 BETWEEN WHAT TVADAD C34OSS STREETS IS PREMISES /LOCAEW, / SECTION / BLOCK I�r L ,.r OCCUPANTS NAME BUILDING OCCURWCY OWNER'S NAME AND ,73 ADDRES � HOME TE�r�+ON NUMBER ,4 o owA G ,7r ,!/�f yO.w .O 14#0#O c f!! I,over6r.r v s ? G tS_.� �? " 4z - / d / 8 CURRENT SUPPLIED UV FROM THEIR OFFICE WORK TELEPHONE NUMBER BUILDNG IS NEW OLD ❑ WORK IS NEW AoorroNAL ❑ DEFECTS REMOVED ❑ LIST BELOW ALL EQUIPMENT WHICH YOU INSTALLED NUMBER OF OUTLETS No. of Fixtures NI MOTORS HEATERS BRANCH OFFICE USE Lamp Receptacles CIRCUITS ONLY lion Side Attach'T Ceiling Wall Recep'Is 9IM" ParKiant Brackei No. Type Each No- Ea n Na Gauge INSPECnON OUT- 51DE SUB- BASE 8A.E- MENT 1gt FL. 2nd FL. 3Td FL. - ,REMARK . LI T OTHER ELECTRICAL 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 LISTED, YOU ARE AUTHORIZED TO MAKE THE INSPECTION AND ADJUST THE FEE TO COVER THE ADDITIONAL EQUIPMENT, AS PROVIDED BY THE APPLICANT. SIZE OF MAINS 'FEEDERS ELEC;aRKC SIGNSA-AMPS TaIALWAFTS C HABACtM OF WORK ❑ EXPOSED OA9 TUBE S'IGNFIRAN SFORMERS OF LPY 11 DATE WORK TO BE STARTED DATE COMPLETED SIZE OF SIGN iNUMBER) CAPACITY SERVICE ENTERS BUILDING —I �/' MANUFACTURER OF SIGN I_ J OVERHEADLQ UNDE+tGip'JVNP DIVE wsTFCrION AEGVESTED ON TOR AS NEAR AS POSSIBLE) �� AfOODAELAYS !3Y FULL RATE INFORMATION. ALL FILLED IN OR APPLICA Y HERNED.RETU PRINT NAME AND ADDRESS NAME [ jAPPLICAN STREET ADDRESS f E NO CITY OR POST OFFICE ,�- ZIP CODE LICENSE N6 WHEN APPLICABLE &AQ 5 7 ,I. / 85 John Street ❑ 41 State Street I ❑ 570 Delaware Avenue ❑ 217 Lake Avenue 4 El202 Arterial Roam NEW YORK, NY 10036 ALBANY, NY 12207 BUFFALO, NY 14202 ROCHESTER, NY 146M I SYRACUSE, NY 13206 THE NEW YORK BOARD OF FIRE UNDERWRITERS