RC-000819-2016 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5904 (518)761-8201
Community Development-Building&Codes (518)761-8256
CERTIFICATE OF OCCUPANCY
Permit Number: RC-000819-2016 Date Issued: Friday, October 13, 2017
This is to certify that work requested to be done as shown by Permit Number RC-000819-2016
has been completed.
Tax Map Number: 227.17-2-22
Location: 15 CHURCHILL RD
Owner: Chad Gates
Applicant: Chad Gates
This structure may be occupied as a:Residential Addition 573 s.f.
By Order of Town Board
TOWN OF QUEENSBURY
Issuance of this Certificate of Occupancy DOES NOT relieve the 4
property owner of the responsibility for compliance with Site Plan,
Variance,or other issues and conditions as a result of approvals by the Director of Building&Code Enforcement
Planning Board or Zoning Board of Appeals.
TOWN OF QUEENSBURY
742 Bay Road.Queensbury,NY 12804-5904 (518)761-8201
ty
Community Development-Building& Codes (518)761-8256
BUILDING PERMIT
Permit Number: RC-000819-2016
Tax Map No: 227.17-2-22
Permission is hereby granted to: Chad Gates
For property located at: 15 CHURCHILL RD
In the Town of Queensbury,to construct or place at the above location in accordance with application together
with plot plans and other information hereto filed and approved and in compliance with the NYS Uniform
Building Codes and the Queensbury Zoning Ordinance
Type of Construction
Owner Name: Chad Gates Single Family-Addition $65,000.00
Owner Address: 106 Cooper ST Total Value $65,000.00
Lake George,NY 12845
Contractor or Builder's Name/Address Electrical Inspection Agency
BBB Construction
4587 Lakeshore DR
Bolton,NY 12814
Plans&Specifications
Residential Addition 573 s.f.
$114.60 PERMIT FEE PAID-THIS PERMIT EXPIRES: Thursday,December 14,2017
(If a longer period is required,an application for an extension must be made to the code Enforcement Officer
of the Town of Queensbury before the expiration date.)
Dated at the Town oP ueens / / 4 W e d tuber l4,2016
SIGNED BY: \ for the Town of Queensbury.
Director of Building&Code Enforcement
j- PRINCIPAL STHU TURE APPLICANeCtconlDate: N I Tax Map ID v � ( l — a -� 2C-0 ,`;bZone Historic? II `1 Cc DSubdivision Name
Project Location \�j Ck�, r-L"Al
TOWN BD.RESOLUTION 86-2013: $850 recreation fee for new dwelling units—single family,duplexes/two-family,multiple family,
apartments,condominiums,townhouses,and/or manufactured&modular homes,but not mobile homes. This is in addition to the
permit feels).
Primary Owner(s) S
Address \5 CEJ q),, \\ CA i C---A veznsli�r� � N� l 2�(J
Phone/Email (�1�7 �,� 1 _� 7 Z-1 �S t�u�0•ca•
Applicant ,
Address 1
Phone/Email
Contractor
Address cg!} � vtz S rJo � St
Phone/Email }p n b lob • a n,Fuld S o(oi,�
Contact Person for Building& Codes Compliance: Phone
TYPE OF CONSTRUCTION
✓Check all that apply New Addition Alteration la floor sf 2nd floor sf Total sf Height
Single Family ✓ 513 S 3
Two-Family
Multi-Family
(#of units
Townhouse
Business Office
Retail-Mercantile
Factory-Industrial
Attached Garage
(1, 2, 3, 4+)
Other
Town of Queens Building&Codes Principal Structure Application revised January 2016
�f `
�. r
If conimercial or industrial please indicate name of business
Proposed use of building or addition
Source of Heat(circle one) Gas Qt Propane Solar Other
Fireplace: Complete a separate application for Fuel Burning
Appliances& Chimneys
Are there structures not shown on plot plan? A110
Are there easements on the property? nl Q
Site Information:
a. Dimensions or acreage of lot o�OG•7 t^4, 15q Tk
b. Is this a corner lot? _Yes �_No
c. Will the grade be changed as a result of construction _Yes _No
d. Public water or Private well (circle one) Public6vat
e. Sewer or Private Septic System(circle one) Sewer Private
Value of all work to be performed (labor or materials) $
DECLARATION.
1. I acknowledge no construction shall be commenced prior to issuance of a valid permit and will be
completed within a 12 month period.
2. If work is not complete by the 1 year expiration date the permit may be renewed, subject to fees and
department approval.
3. I certify that the application, plans and supporting materials are a true and complete statement /
description of the work proposed, that all work will be performed in accordance with the NYS
Building Codes,local building laws and ordinances,and in conformance with local zoning regulations
4. I acknowledge that prior to occupying the facilities proposed, I or my agents will obtain a certificate
of occupancy.
5. I also understand that I /we are required to provide an as-built survey by a licensed land surveyor of
all newly constructed facilities prior to issuance of a certificate of occupancy.
I have read and agree to the above:
PRINTNAME: GAS DATE:
SIGNATURE: DATE:
For office use only
Operating Permit Issued: _Yes —No
Occupancy Type
Construction Classification
Assembly Occupancy Limit
Special Conditions
Town of Queensbury Building&Codes Principal Structure Application Revised January 2016
REScheck Software Version 4.6.2
Compliance Certifiq4te N
00
co
b
CD «'
Project Gates Residence 1J0 30 w,,� /�l o
U
Energy Code: 2015 IECC TOWN OF pU V
Location: Warren County, New York BUILDING$COSBURY p
Construction Type: Single-family DES N !=
Project Type: Addition 0 -0
Climate Zone: 6 (8499 HDD) 04 'G Q
Permit Date:
Ntt (0
Permit Number: C4 () ±' 5
7
Construction Site: Owner/Agent: Designer/Contractor: y
15 Churchill Lane Chad&Lauren Gates Curtis Dybas
Queensbury, NY 12804 106 Cooper Street 19 Deer Run N ur)
Lake George,NY 12845 Lake George, NY 12845
518 668 5818 518 668 5591
cdybas@yahoo.com
Compliance: Passes using UA trade-off
Compliance: 6.1%Better Than Code Maximum UA: 115 Your UA: 108
The%Better or Worse Than Code Inde.reflects how close to compliance the house is based on code trade-off rules.
It DOES NOT provide an estimate of energy use or cost relative to a minimum-code home.
Envelope Assemblies
Gross Area Cavity Cant.
Assembly or U-Factor UA
Ceiling 1: Cathedral Ceiling 82 38.0 0.0 0.027 2
Ceiling 2: Flat Ceiling or Scissor Truss 425 38.0 0.0 0.030 13
Wall 1: Wood Frame, 16" o.c. 1,053 21.0 5.0 0.043 41
Window 1: Wood Frame:Double Pane with Low-E 64 0.300 19
Door 1: Solid 42 0.077 3
Wall 2: Wood Frame, 16"D.E. 140 21.0 0.0 0.057 8
Floor 1:All-Wood joist/rruss:Over Unconditioned Space 472 30.0 0.0 0.033 16
Floor 2:Slab-On-Grade:Unheated 6 10.0 1.042 6
Insulation depth:0.0'
Compliance Statement The proposed building design described here is consistent with the building plans,specifications, and other
calculations submitted with the permit application.The proposed building has been designed to meet the 2015 IECC requirements in
REScheck Version 4.6.2 and to comply with the mandatory requir ents listed\ �Eck Inspection Checklist.
`�JYLr)�i t7 n�� t2iJ �i.c.c�
Name-Ti le Signature Date
Project Title: Gates Residence Report date: 11/23/16
Data filename: C:\Users\Curtis\Documents\Gates Residence\Untitled.rck Page 1 of 9
REScheck Software Version 4.6.2
Inspection Checklist
Energy Code: 2015 IECC
Requirements: 39.0% were addressed directly in the REScheck software
Text in the "Comments/Assumptions" column is provided by the user in the REScheck Requirements screen. For each
requirement, the user certifies that a code requirement will be met and how that is documented, or that an exception
is being claimed.Where compliance is itemized in a separate table, a reference to that table is provided.
Section Plans Verified Field Verified
# Pre-Inspection/Plan Review value Value Complies? Comments/Assumptions
&R .ID
103.1, Construction drawings and [ Complies Requirement will be met.
103.2 documentation demonstrate ❑Does Not
[PRI]1 energy code compliance for the
y-. building envelope.Thermal []Not Observable
envelope represented on []Not Applicable
construction documents.
103.1, Construction drawings and ❑Complies
103.2, documentation demonstrate ❑Does Not
403.7 energy code compliance for
[PR3]1 lighting and mechanical systems. ❑Not Observable
Systems serving multiple ❑Not Applicable
dwelling units must demonstrate
compliance with the IECC
Commercial Provisions.
302.1, Heating and cooling equipment is Heating: Heating: [ Complies
403.7 sized per ACOA Manual S based Btu/hr Btu/hr_ ❑Does Not
[PR2]2 on loads calculated per ACOA Cooling: Cooling: []Not Observable
Manual J or other methods Btu/hr_ Btu/hr_
approved by the code official. ❑Not Applicable
Additional Comments/Assumptions:
1 I High Impact(Tier 1) 2 Medium Impact(Tier 2) 3 1 Low Impact(Tier 3)
Project Title: Gates Residence Report date: 11/23/16
Data filename: C:\Users\Curtis\Documents\Gates Residence\Untitled.rck Page 2 of 9
Section Plans Verified Field Verifled
# Foundation Inspection Value Value Complies? Comments/Assumptions
&Re .ID
402.1.2 Slab edge insulation R-value. R- R- []Complies See the Envelope Assemblies
[FO111 ❑ Unheated ❑ Unheated ❑Does Not table for values.
❑ Heated ❑ Heated [_]Not Observable
❑Not Applicable
402.1.2 Slab edge insulation _ft _It ❑Complies See the Envelope Assemblies
[F0311 depth/length. ❑Does Not table for values.
1C
[]Not Observable
❑Not Applicable
303.2.1 A protective covering is installed []Complies Exception: Requirement Is
[FO1112 to protect exposed exterior []Does Not not applicable.
insulation and extends a ❑Not Observable
minimum of 6 in.below grade.
❑Not Applicable
403.9 Snow-and Ice-melting system ❑Complies
controls installed. []Does Not
L []Not Observable
[]Not Applicable
Additional Comments/Assumptions:
1 I High Impact(Tier 1) 2 Medium Impact(Tier 2) 3 1 Low Impact(Tier 3)
Project Title: Gates Residence Report date: 11/23/16
Data filename: C:\Users\Curtis\Documents\Gates Residence\Untitied.rck Page 3 of 9
Section plans Verified Field Verlfled
# Framing/Rough-in Inspection Value d alueVeri Complies? Comments/Assumptions
&Req.
402.1.1, Door U-factor. U-_ U-_ ❑Complies See the Envelope Assemblies
402.3.4 ❑Does Not table for values.
[FR111 []Not Observable
14 ❑Not Applicable
402.1.1, Glazing U-factor(area-weighted U-_ U-_ ❑Complies See the Envelope Assemblies
402.3.1, average). ❑Does Not table for values.
402.3.3, []Not Observable
402.3.6,
402.5 []Not Applicable
[FR2]1
uJ
303.1.3 U-factors of fenestration products ❑Complies Requirement will be met.
[FR411 are determined in accordance ❑Does Not
with the NFRC test procedure or ❑Not Observable
taken from the default table. ❑Not Applicable
402.4.1.1 Air barrier and thermal barrier ❑Complies Requirement will be met.
[FR23]1 installed per manufacturer's ❑Does Not
#9 instructions. ❑Not Observable
❑Not Applicable
402.4.3 Fenestration that is not site built ❑Complies Requirement will be met.
[FR2011 is listed and labeled as meeting ❑Does Not
AAMA/WDMAICSA 101/1.5.2/A440 [3Not Observable
or has infiltration rates per NFRC
400 that do not exceed code ❑Not Applicable
limits.
402.4.5 IC-rated recessed lighting fixtures ❑Complies Requirement will be met.
[FR16]2 sealed at housing/interior finish ❑Does Not
and labeled to indicate<_2.0 cfm []Not Observable
leakage at 75 Pa.
[]Not Applicable
403.2.1 Supply and return ducts in attics ❑Complies
[FR32]1 insulated>=R-8 where duct is ❑Does Not
>= 3 inches in diameter and >_ ❑Not Observable
R-6 where<3 inches.Supply and
return ducts in other portions of ❑Not Applicable
the building insulated>=R-6 for
diameter=3 inches and R-4.2
for<3 inches in diameter.
403.3.3.5 Building cavities are not used as ❑Complies
[FR1513 ducts or plenums. ❑Does Not
to ❑Not Observable
❑Not Applicable
403.4 HVAC piping conveying fluids R-_ R-_ ❑Complies
[FR17]2 above 105 QF or chilled fluids ❑Does Not
I , below 55 vF are Insulated to aR- ❑No[Observable
3. ❑Not Applicable
403.4.1 Protection of insulation on HVAC ❑Complies
[FR2411 piping. ❑Does Not
d, []Not Observable
❑Not Applicable
403.5.3 Hot water pipes are Insulated to R-_ R-_ ❑Complies
[FR18]2 aR-3. ❑Does Not
114 ❑Not Observable
❑Not Applicable
403.6 Automatic or gravity dampers are ❑Complies Requirement will be met.
[FR19]2 installed on all outdoor air []Does Not
intakes and exhausts.
❑Not observable
❑Not Applicable
11 High Impact(Tier 1) 12 J Medium Impact(Tier 2) 3 1 Low impact(Tier 3)
Project Title: Gates Residence Report date: 11/23/16
Data filename: C:\Users\Curtis\Documents\Gates Residence\Untitled.rck Page 4 of 9
Additional Comments/Assumptions:
1 High Impact(Tier 1) 12 IMedium Impact(Tier 2) 3 1 Low Impact(Tier 3)
Project Title: Gates Residence Report date: 1123/16
Data filename: C:\Users\Curtis\Documents\Gates Res!dence\Untitled.rck Page 5 of 9
Section Plans Verified Field Verified
# Insulation Inspection Value Value Complies? Comments/Assumptions
&Req.
303.1 All installed insulation is labeled ❑Complies Requirement will be met.
[IN13]2 or the installed R-values ❑Does Not
provided. ❑Not Observable
❑Not Applicable
402.1.1, Floor insulation R-value. R- R- ❑Complies See the Envelope Assemblies
402.2.6
]7 []Does F1 Wood []Does Not table for values.
[IN131 ❑ steel ❑ Steel ❑Not Observable
#4' ❑Not Applicable
303.2, Floor insulation installed per ❑Complies Requirement will be met.
402.2.7 manufacturer's Instructions and ❑Does Not
[IN231 in substantial contact with the ❑Not Observable
�. underside of the subfloor, or floor
framing cavity insulation is in ❑Not Applicable
contact with the top side of
sheathing,or continuous
Insulation is installed on the
underside of floor framing and
extends from the bottom to the
top of all perimeter floor framing
members.
402.1.1. Wall insulation R-value. If this Is a R- R- ❑Complies See the Envelope Assemblies
402.2.5, mass wall with at least%of the ❑ Wood ❑ Wood ❑Does Not table for values.
402.2.6 wall insulation on the wall ❑ Mass ❑ Mass []Not Observable
[IN331 exterior,the exterior insulation
0 requirement applies(FR10). ❑ Steel ❑ Steel ❑Not Applicable
303.2 Wall insulation is installed per ❑Complies Requirement will be met.
[IN431 manufacturer's instructions. ❑Does Not
[]Not Observable
[]Not Applicable
Additional Comments/Assumptions:
1 I High Impact(Tier 1) 2 Medium Impact(Tier 2) 1 3 1Low Impact(Tier 3)
Project Title: Gates Residence Report date: 1123/16
Data filename: C:\Users\Curtis\Documents\Gates Residence\Untitled.rck Page 6 of 9
Section Plans Verified Field Verified
# Final Inspection Provisions Value Value Complies? Comments/Assumptions
&R .ID
402.1.1, Ceiling Insulation R-value. R- R- ❑Complies See the Envelope Assemblies
402.2.1, Wood table for values.
402.2.2, ❑ ❑ Wood ❑Does Not
402.2.6 ElSteel ❑ Steel ❑Not Observable
[Fill' ❑Not Applicable
303.1.1.1, Ceiling insulation installed per ❑Complies Requirement will be met.
303.2 manufacturer's Instructions. ❑Does Not
[FI2]1 Blown Insulation marked every
[]Not ft'. Not Observable
❑Not Applicable
402.2.3 Vented attics with air permeable ❑Complies Requirement will be met.
[FI22]2 insulation include baffle adjacent ❑Does Not
to soffit and eave vents that
extends over insulation. ❑Not Observable
❑Not Applicable
402.2.4 Attic access hatch and door R-_ R-_ ❑complies Requirement will be met.
IFI311 insulation 2:11-value of the ❑Does Not
adjacent assembly. ❑Not Observable
❑Not Applicable
402.4.1.2 Blower door test @ 50 Pa. <=5 ACH 50=_ ACH 50 =_ ❑Complies Requirement will be met.
[FI1711 ach in Climate Zones 1-2, and ❑Does Not
<=3 ach In Climate Zones 3-8. ❑Not Observable
❑Not Applicable
403.2.3 Duct tightness test result of<=4 cfm/100 cfm/100 ❑Complies
IFI411 cfm/100 ft2 across the system or ft2 ft' ❑Does Not
<=3 cfm/100 ft2 without air ❑Not Observable
handler @ 25 Pa. For rough-in
tests,verification may need to ❑Not Applicable
occur during Framing Inspection.
403.3.2 Ducts are pressure tested to dm/100 cfm/100 ❑Complies
[FI2711 determine air leakage with ft' ft2 ❑Does Not
either: Rough-in test:Total ❑Not Observable
leakage measured with a ❑Not Applicable
pressure differential of 0.1 inch
w.g.across the system including
the manufacturer's air handler
enclosure if installed at time of
test. Postconstruction test:Total
leakage measured with a
pressure differential of 0.1 inch
w.g.across the entire system
including the manufacturer's air
handler enclosure.
403.3.2.1 Air handler leakage designated ❑Compiles
(FI2411 by manufacturer at<=2%of ❑Does Not
design air flow. ❑Not Observable
❑Not Applicable
403.1.1 Programmable thermostats [ Complies
[F]912 installed for control of primary ❑Does Not
heating and cooling systems and ❑Not Observable
Initially set by manufacturer to
code specifications. ❑No[Applicable
403.1.2 Heat pump thermostat installed ❑Complies
[FI10]2 on heat pumps. ❑Does Not
❑Not Observable
❑Not Applicable
403.5.1 Circulating service hot water ❑complies
[FI11]1 systems have automatic or ❑Does Not
accessible manual controls. ❑Not Observable
❑Not Applicable
11 High impact(Tier 1) 12 iMedium Impact(Tier 2) 3 Low Impact(Ter 3)
Project Title: Gates Residence Report date: 1123/16
Data filename: C:\Users\Curtis\Documents\Gates Residence\Untitled.rck Page 7 of 9
Section Plans Verified Field Verified
# final Inspection Provisions
&Re .ID I I
Value Value Complies? Comments/Assumptions
403.6.1 All mechanical ventilation system ❑Complies
[F125]2 fans not part of tested and listed ❑Does Not
HVAC equipment meet efficacy
and air flow limits. ❑Not Observable
❑Not Applicable
403.2 Hot water boilers supplying heat ❑Complies
[F126]2 through one-or two-pipe heating []Does Not
systems have outdoor setback
control to lower boiler water ❑Not Observable
temperature based on outdoor ❑Not Applicable
temperature.
403.5.1.1 Heated water circulation systems ❑Complies
[F12812 have a circulation pump.The ❑Does Not
system return pipe is a dedicated
return pipe or a cold water supply ❑Not Observable
pipe.Gravity and thermos- ❑Not Applicable
syphon circulation systems are
not present.Controls for
circulating hot water system
pumps start the pump with signal
for hot water demand within the
occupancy.Controls
automatically tum off the pump
when water is in circulation loop
is at set-point temperature and
no demand for hot water exists.
403.5.1.2 Electric heat trace systems ❑Complies
[F12912 comply with IEEE 515.1 or UL []Does Not
515. Controls automatically ❑Not Observable
adjust the energy input to the
heat tracing to maintain the ❑Not Applicable
desired water temperature in the
piping.
403.5.2 Water distribution systems that ❑Complies
[F130]2 have recirculation pumps that ❑Does Not
pump water from a heated water ❑Not Observable
supply pipe back to the heated ❑Not Applicable
water source through a cold pp
water supply pipe have a
demand recirculation water
system. Pumps have controls
that manage operation of the
pump and limit the temperature
of the water entering the cold
water piping to 1049F.
403.5.4 Drain water heat recovery units ❑Complies
[FI3112 tested in accordance with CSA []Does Not
B55.1.Potable water-side ❑Not Observable
pressure loss of drain water heat
recovery units<3 psi for ❑Not Applicable
individual units connected to one
or two showers.Potable water-
side pressure loss of drain water
heat recovery units<2 psi for
individual units connected to
three or more showers.
404.1 75%of lamps in permanent ❑Complies
[FI6]1 fixtures or 75%of permanent ❑Does Not
fixtures have high efficacy lamps. ❑Not Observable
Does not apply to low-voltage
lighting. ❑Not Applicable
404.1.1 Fuel gas lighting systems have ❑Complies
[F123]3 no continuous pilot light. ❑Does Not
y ❑Not Observable
❑Not Applicable
1 I High Impact(Tier 1) 2 Medium impact(Tier 2) 3 1 Low Impact Cher 3)
Project Title: Gates Residence Report date: 1123/16
Data filename: C:\Users\Curtis\Documents\Gates Residence\Untitied.rck Page 8 of 9
Section Plans Verified Field Verified
# Final Inspection Provisions value Value Complies? Comments/Assumptions
& Re .ID
401.3 Compliance certificate posted. ❑Complies Requirement will be met.
[FI712 ❑Does Not
[]Not Observable
❑Not Applicable
303.3 Manufacturer manuals for ❑Complies
[FI1813 mechanical and water heating ❑Does Not
systems have been provided. ❑Not Observable
❑Not Applicable
Additional Comments/Assumptions:
1 I High Impact(Tier 1) 2 Medium Impact(Tier 2) 3 1 Low Impact(Tier 3)
Project Title: Gates Residence Report date: 1123/16
Data filename: C:\Users\Curtis\Documents\Gates Residence\Untitled.rck Page 9 of 9
�( 2015 IECC Energy
j Efficiency Certificate
Insulation Rating R-Value
Above-Grade Wall 26.00
Below-Grade Wall 0.00
Floor 30.00
Ceiling / Roof 38.00
Ductwork (unconditioned spaces):
Glass&Door Rating U-Factor SHGC
Window 0.30
Door 0.08
Heating&Cooling Equipment Efficiency
Heating System:
Cooling System:
Water Heater:
Name: Date:
Comments
227.17-2-22 RC-000819-2016
Gates, Chad 1�
15 Churchill Road ��,� RSD ^Rc �-
t�5 O.
_ Residential Addition 573 s.f. �•�'� �;
�y7\
Jy
.. l u.. O r"��l S G O
TOWN OF QDBBN SBURY A , : C 1140
`
BUILDING I& COVS :—Reviewed': `: _Date: FT;,,
. I
5
TOWN OF QUEENSSURYC
0
BUILDING DEPARTMENT ' O
� � iJ om`
Based on our limited examination,compliance
with our comments shall not be construed as o O Q
indicating the plans and specifications are in
I full compliance with the Building Godes of .E� t— - z
New Yod(State. C { G)D
M ® �
m ; rn
NOTICE o r:.
FOAM INSULATION MUST BE c ' o I� C iJ
COVERED BY A 15 MINUTE m~' m rn
THERMAL BARRIER `At ,
9t
MO-EK-E
KRAFT PA !=- ;N('!Jl ATIl.J1Y
NON-C-Ci `Ll
"
u
NOTICE.,
Smoke detectors are required in bedrooms A � \ l
adjacent to bedrooms and on each flc: �r.
level including cellar or basement ��' 40°oa ,:
All smoke detectors&carbon monoxide ,
detectors shall be Interconnnected %with
battery backup and located on all.levels.
utspn8 detectors
allvlsOsidde )eeig ad on levels. 0 0(56,
j
COMMONWEALTH ELECTRICAL INSPECTION SERVICE,INC.
Main Office 176 Doe Run Road-Manheim,PA 17545
MUNICIPAL CERTIFICATE - ELECTRICAL APPROVAL
19- 2m t b
Permit No........................................Gert. NO 44850 Cut-in Card No.....................................
Owner.............�,e......i-''...1�.7,,I zn—s..........
..................................................................................
Location................C..t Vii .f/ I L�-......X e...........................................a(e.._.46 ... ..................
Installation Consisting of. L... .....j. iC;.lTt '..Ar:�Pr.2..... .. ...........
-................................................................................
............................;.r.—.
. .... ............................�............................................................................................................
Installed By....1.r..' .1.-zA�'.� 'VW....................................Lic.No...................................................
The conditions following governed the issuance of this certificate,and any certificate previously issued is
cancelled:-
This certificate only covers the electrical equipment and installation conditions as of date. Upon the
introduction of additional equipment or alterations,application shall be promptly made for inspection.
Inspectors of this Company shall have the privilege of makin spections at any time, and if its
rules are violated,the Company shall have the right-toere t ' ficate.
r _✓
Date....... -!..7.................. INSPECTOR...... ....l.... . .....ry....... Y'•,,...................................
Member N.F.P.A.,I.A.E.I.