96-639 BUILDING PERMIT
VALUE $ 0 TOWN OF QUEENSBURY No 96639
TAX MAP NO. 21. -1-8. 1 WARREN COUNTY, NEW YORK
PERMISSION is hereby granted to LINDAHL, VON/DENTON
OWNER of property located at 2297 RIDGE RD. Street, Road or Ave.
in the Town of Queensbury,To Construct or place a CERTIFICATE OF OCCUPANCY
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
2297 RIDGE ROAD
QUEENSBURY, NY 12804
2. CONTRACTOR or BUILDER'S Name
LINDAHL, VON
3. CONTRACTOR or BUILDER'S Address
4. ARCHITECT'S Name
COMMONWEALTH ELECTRICAL AGENCY
5. ARCHITECT'S Address
PO BOX 706
HAGUE, NY 12836
6. TYPE of Construction— (Please indicate by X)
CERTIFICATE OF OCCUPANCY ONLY
( )Wood Frame ( ) Masonry ( I Steel ( )
7. PLANS and Specifications
CERTIFICATE OF OCCUPANCY ONLY
REPAIR DUE TO FIRE DAMAGE
8. Proposed Use
CERTIFICATE OF OCCUPANCY
$ 25 PERMIT FEE PAID —THIS PERMIT EXPIRES October 28 19 98
(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.)
28 October 19 96
Dated at the Town of Queensbury this Day of
SIGNED BY '�r � _ for the Town of Queensbury
Elul *mg and Zoning In ctor
Building Permit Application
Town of Queensbury - Dept. of Community Development, 742 Bay Road, Queensbury, NY 12804 1761-8256J
° BUILDING & CODE ENFORCEMENT
NOTICERequirements prior to issuance r C /
A permit must be obtained before
f(1' ^(D 39
of this permit: PERMIT FILE NO.
beginning construction. No inspections UI,1
will be made until applicant has received f-7 Zoning Board Action PERMIT FEE PAID$ .2S'
a VALID BUILDING PERMIT. All Area /Use RECREATION FEE PAID$
applicants' spaces on this application
MUST be completed and the signature fl Planning Board Action REVIEWED BY. r�
of the applicant must appear on the
wpplication form. rn,,,,,t y.,,. SPR / Subdivision /Other Building Inspector J
.J , Recreation Fee Payment
Applicant: V s R,, ir. Owner: 196- Cl..ic.L .-
Address: 4:17 .3 t a is.i1 ar4% ef1c..-iyAddress: c ` c_
Phone # ( ) S c- •� 1 L/ / Phone # ( 5 t-
rA.—
Property I,oeation: -a w,..- Er' _
fax Map Number —J
Subdivision Name: —
Section Block Lot
NATURE OF PROPOSED WORK: ESTIMATED MARKET VALUE OF THE
New Building: CONSTRUCTION: $ c oLOt.
residence / commercial
Addition to Building:
residence / commercial OCCUPANCY INFORMATION:
Alteration to Building: Primary Building -
residence / commercial X Single Family Dwelling
Residence / Commercial Two Family Dwelling
no change to exterior size Family Dwelling
Office
ZOA,ther ( ribe below) Mercantile
c, ..., ��. ,-,, Manufacturing ,
Other
GROSS AREA OF PROPOSED STRUCTURE: /�
1st Floor / sq. ftG�-�5T) If ADDITION, what will use
2nd .Floor 440 sq. ftaC[5T of new addition be?
Other Floors sq. ft. N
(not unfinished cellar or basement) ACCESSORY BUILDINGS:
Detached Garage 1, 2 car
TOTAL FLOOR AREA: /OM SQ. FT. ttac arage 1, 2 car
Pri orage Building
SIZE OF NEW STRUCTURE: Comm c' torage Building
Other
FEET X FEET
Foundation Type: i0 ,ac ° , Will any second-hand or ungraded
Number of Stories : '. lumber be used? If so, for what?
(habitable space only)
Height (grade to ridge) : feet TYPE OF HEATING SYSTEM:
Number of fireplaces nd/or woodstove (circle all which applies
to be installed: mg. Electric / Oil Gas / �oo0
arced Hot / Basebo / Other
Person responsible for supervision of work as regards to building
codes is : ‹c,,...,, r
Name Addresss Phone
Builder:
Plumber:
Mason:
Electrician:
DECLARATION: Please sign below after you have carefully read the statement.
To the best of my knowledge 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 noted, and
that such work is authorized by the owner. Further, it is understood that I/we shall submit prior to a
Certificate of Occupancy'or Certificate of Compliance being issued, an AS BUILT PLOT PLAN by
a licensed surveyor; drawn to scale, showing actual location of project on premises.
'/Signature: 4-c- t.r�n 4 v i n-:,.
(ownervner's agent, architect, contractor)
MC>T\CI)Ctk (518) 761-8256
TOWN OF QUEENSBURY
BUILDING & CODE ENFORCEMENT I
742 BAY RD., QUEENSBURY NY 12804
/-,_.,_,
INSPECTOR'S REPORT: ARR/ DEPART� I, ifREQUEST FO INSPECT ON RECEIVED: ')-1 — I7
ta
NAME 1 A�L.LOCATION 0g_ ei ; A -x,_
DATE Li —all` ci--7 PERMIT # a (3c
TYPE OF STRUCTURE:
RECHECK APPROVED
N/A YES NO
FOOTINGS/P ERS
MONOLITHIC OUR FORM
REINFORCEME T IN PLACE
THE CONTRAC R IS RESPONSIBLE F•R
PROVIDING PR TE TION FROM FREE ING
FOR 48 HOURS OLLOWING THE P CE-
MENT OF THE C NCRETE.
MATERIALS FOR HIS PURPOSE op SITE
e
FOUNDATION/WALIyOUR (
REINFORCEMENT I PLACE i'
FOUNDATION/DAMPP OFING ii
BACKFILL APPROVAL`
PLUMBING VENT/VENTk IN PLACE
ROUGH PLUMBING _
\ f
PLUMBING UNDER SLAB ?�
/FRALUMING: _N/I:
JACK STUDS/H A .ERS w r
BRACING BR D IN _
JOIST RANGE S
JACK POSTS/7IAIN BEAM _ -
lI
AIR INFILTRATION BRRIER _
HEATING ROUGH-IN
t
INSULATION: ' _
FOUNDATION WA 'LS INTERIOR 1t- _
FOUNDATION WA LS EXTERIOR A-
FLOORS R-
WALLS G R-4�-
CEILIN R �_
DUCT WORK O PIPING IN
UNHEATED SP CES R-
.
(518) 761-8256
TOWN OF QUEENSBURY (Pb
BUILDING & CODE ENFORCEMENT
742 BAY RD., QUEENSBURY NY 12804
INSPECTOR'S REPORT: ARR,a[.`(D DEPART IN'O/
REQUEST FOR INSPEZ:ITIVED:
NAME �L/////,�
LOCATION /� 1,7 Gy
DATE 7 PERMIT I /� - 639
TYPE OF STRUCT RE:
RECHECK APPROVED
N/A YES NO
FOOTINGS/PIERS
MONOLITHIC POUR FORM
REINFORCEMENT IN PUCE
THE CONTRACTOR IS R ONSIHLE FOR
PROVIDING PROTE TIO FROM FREEZING
FOR 48 HOURS FOLLO I G THE PLACE-
MENT OF THE CONC TE.
MATERIALS FOR HIS PURPOSE ON SITE,
FOUNDATION/WALLPOUR
REINFORCEMENT IN PLACE
FOUNDATION/DAMPPROOFING
BACKFILL APPROVAL
PLUMBING VENT/VENTS IN PLACE
ROUGH PLUMBING
PLUMBING UNDER SLAB
FRAMING:
JACK STUDS/HEADERS
BRACING/BRIDGING
JOIST HANGERS
JACK POSTS/MAIN BEAM
AIR INFILTRATION BARRIER
HEATING ROUGH-IN
INSULATION:
FOUNDATION WALLS INTERIOR R-
FOUNDATION WALLS EXTERIOR R-
FLOORS R-
WALLS R-
CEILING R-
DUCT WORK OR PIPING IN
UNHEATED SPACES R-
_1401,74 /G1, /tea/
Gam,/l C411 4- ix-re A4,4-
(518) 761-8256
TOWN OF QUEENSBURY
BUILDING & CODE ENFORCEMENT
742 BAY RD., QUEENSBURY NY 12804
INSPECTOR'S REPORT: ARFj0('3�' DEPART INT -
REQUEST FOR INSPECTIONIECEIVED:
NAME
LOCATION L�{
DATE ! f PERMIT 1
Q16-(193C
TYPE OF STRU TURE:
RECHECK APPROVED
N/A YES NO
FOOTINGS/PIERS
MONOLITHIC POUR FO _
REINFORCEMEN IN PLACE
THE CONTRACTOR IS RESPON BLE FOR
PROVIDING PROTE TION FRO FREEZING
FOR 48 HOURS FOLLOWING PLACE-
MENT OF THE CONCRETE.
MATERIALS FOR THIS PURPOSES ON SITE
FOUNDATION/WALLPOUR
REINFORCEMENT IN PLACE
FOUNDATION/DAMPPROOFING -
BACKFILL APPROVAL
PLUMBING VENT/VENTS IN PLACE ,.
ROUGH PLUMBING _
PLUMBING UNDER SLAB -
FRAMING:
JACK STUDS/HEADERS
BRACING/BRIDGING
JOIST HANGERS
JACK POSTS/MAIN BEAM
AIR INFILTRATION BARRIER
HEATING ROUGH-IN
INSULATION:
FOUNDATION WALLS INTERIOR R-
FOUNDATION WALLS EXTERIOR R-
FLOORS R-
WALLS R-
CEILING R-
DUCT WORK OR PIPING IN
UNHEATED SPACES R-
4/t(7 6/&- _4150 4d.4.-,
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TOWN OF QUEENSBURY
BUILDING & CODE ENFORCEMENT
� � 742 BAY ROAD
�` QUEENSBURY NY 12804
(518)745-4447
ARRIVE: r;,2w� DFPT.RT: INSP: j=- —
FINAL INSPECTION REPORT - RESIDENTIAL
DATE NAME IN$PE�OO�RESIT�EQE(�
LOCATION l 1���11//��
CZ
-_.__
DATE PERMIT N
TYPE OF STRUCTURE
FOOTINGS FOUNDATION BACKFILL FRAMING
ROUGH PLUMBING _ SEPTIC _ INSULATION
FINAL ELECTRICAL WOODSTOVE OR FIREPLACE
N/A YES NO
CHIMNEY HEIGHT/B VENT/HEIGHT
PLUMBING VENT
ROOFING
EXTERIOR FINISH
DECK/PORCH/STEPS/RAILINGS
RELIEF VALVES
FURNACE/HOT WATER OPERA G
INTERIOR TRIM/PRIVAC ORS
FINISH FLOORS: i
BATH/KITCHEN WATERTIGHT
OTHER FLOORS 'SWEEPABLE
OTHER FLOORS CARPETED
STAIR CLEARANCE/RAILINGS
SMOKE DETECTORS
BATHROOM FANS
PLUMBING FIXTURES
FOUNDATION INSULATION
GARAGE FIRE PROOFING
DOOR CLOSERS G
FINAL ELECTRICAL �s / i a
SITE PLAN/VARIANCE REO.
FINAL SURVEY PLOT PLAN
OK TO ISSUE C/O OR C/C
3 A L4 J /f cis&/ G�
TOWN OF QUEENSBURY C , nn „
BUILDING & CODE ENFORCEMENT /�
742 BAY ROAD12
/•�' QUEENSBURY NY 12604
(518)745-4447
ARRIVE: /' DEPART: INSP:
FINAL INSPECTION REPORT - RESIDENTIAL
DATE INSPECTIO REQUEST R EIVED: / 0 53 -�
NAME 41,44,e jt I
LOCATION
DATE / S C PERMIT pt. 63 g
TYPE OF STRUCTURE G/ L)
FOOTINGS FOUNDATION BACKFILL FRAMING
ROUGH PLUMBING SEPTIC INSULATION
FINAL ELECTRICAL WOODSTOVE OR FIREPLACE
N/A YES NO
CHIMNEY HEIGHT/B VENT/HEIGHT
PLUMBING VENT
ROOFING
EXTERIOR FINISH
DECK/PORCH/STEPS/RAILINGS
RELIEF VALVES
FURNACE/HOT WATER OPERATI
INTERIOR TRIM/PRIVA DOORS
• FINISH FLOORS:
BATH/KITCHEN WATERTIGHT
OTHER FLOORS SWEEPABLE
OTHER FLOORS CARPETED
STAIR CLEARANCE/RAILINGS
SMOKE DETECTORS
BATHROOM FANS
PLUMBING FIXTURES
FOUNDATION INSULATION
GARAGE FIRE PROOFING
DOOR CLOSERS
FINAL ELECTRICAL
SITE PLAN/VARIANCE REQ.
FINAL SURVEY PLOT PLAN
OK TO ISSUE C/O OR C/C
it Z/,t4/ /40.
filo �/ -
TOWN OF QUEENSBURY
BUILDING & CODE ENFORCEMENT
1111) 742 BAY ROAD
QUEENSBURY NY 12804
(518) 761-8256
ARRIVE: n/' DEPART: INSP:
FINAL INSPECTION REPORT
COMMERCIAL MULTIPLE DWELLING
(hotel, motel, apt. complex)
DATE INSPECTION EQUEST RECE VED:
NAME, l
LOCATION / �C
DATE or PERMIT #
TYPE OF STRUCTURE
FOOTINGS BACKFILL FRAMING PLUMBING
INSULATION
N/A YES NO
CHIMNEY/"B" VENT/HEIGHT
PLUMBING VENT/FIXTURES
ROOFING
EXTERIOR FINISH
HEATING/HOT WATER \
RELIEF VALVES
FLOORS
FOUNDATION INS TION
INTERIOR STAIRJRAILI GS
STOCKROOM ENCLOSURE
FIRE/DEMISE WALLS PENETRATION
FIRE DAMPERS
CEILING FIRE STOPPING
FIRE DOORS/CLOSERS
EXIT DOOR HARDWARE
EXIT STAIRS/RAILS _
PLATFORM_/ELEVATOR
HANDICAPPED ACCESS
HANDICAPPED BATHS
HANDICAPPED PARKING
FINAL ELECTRICAL
SITE PLAN/VARIANCE REO.
FINAL SURVEY PLOT PLAN, IF REQ,
OK TO ISSUE C/O OR C/C .
C
/�� _TOM OF QUEENSBURY
� o"1� ,---BVILDING & CODE ENFORCEMENT
742 BAY ROAD
• QUEENSBURY NY 12804
(518) 761-8256
ARRIVE: 31/0 DEPART: INSP:
4111121PSPECTION REPORT - RESIDENTIAL g+ Q
DATE INSPECTION R QUEST RECEIVED: 1
NAME `
LOCATION
DATE _la ( )9d=1:2 P RMIT N (04 I)3
TYPE OF STR CTURE
FOOTINGS FOUNDATION BACK ILL _ F AM NG
ROUGH PLUMBING _ SEPTIC _ INSULATION
FINAL ELECTRICAL WOODSTOVE OR FIREPLA
N/A YES NO
CHIMNEY HEIGHT/B VENT/H IGHT
PLUMBING VENT
ROOFING
EXTERIOR FINISH
DECK/PORCH/STEP RAILINGS
RELIEF VALVE
y
FURNACE/HOT WATER OPERATING
INTERIOR TRIM/PRIVACY DOORS
FINISH FLOORS:
BATH/KITCHEN WATERTIGHT
OTHER FLOORS SWEEPABLE
OTHER FLOORS CARPETED
STAIR CLEARANCE/RAILINGS
SMOKE DETECTORS
BATHROOM FANS
PLUMBING FIXTURES
FOUNDATION INSULATION
GARAGE FIRE PROOFING
DOOR CLOSERS
FINAL ELECTRICAL
SITE PLAN/VARIANCE REQ.
FINAL SURVEY PLOT PLAN
OK TO ISSUE C/O OR C/C
a 1‘ 1/94,7 +
— Sec o't APR-
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45174%, e)0/1,4),-- 14,c/- I ter.-
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(518) 761-8256
TOWN OF QUEENSBURY
BUILDING F. CODE ENFORCEMENT
742 BAY RD. , QUEENSBURY NY 12804
INSPECTOR'S REPORT: ARR/r3' DEPART INZ
REQUEST FOR INSPECTION RECEIVED: < C) " j 7 v 9 L`)
j
NAME hNc: 4A_
LOCATION �� �
DATE /CD - 1 `�{ PERMIT I�- �`� �3CA
TYPE OF STRUCTURE: l C_1 C
RECHECK APPROVED
N/A YES NO
FOOTINGS/PIERS
MONOLITHIC POUR FORM
REINFORCEMENT IN PLACE
THE CONTRACTOR IS RESPONSIBLE FOR
PROVIDING PROTE TION FROM FREEZING
FOR 48 HOURS FOLLOWING THE PLACE-
MENT OF THE CONCRETE.
MATERIALS FOR THIS PURPOSE ON SITE
FOUNDATION!WALLPOUR
REINFORCEMENT IN PLACE
FOUNDATION/DAMPPROOFING
BACKFILL APPROVAL /
PLUMBING VENT/VENTS IN PLACE ✓
ROUGH PLUMBING
PLUMBING UNDER SLAB
FRAMING:
JACK STUDS/READERS
BRACING/BRIDGING
JOIST HANGERS
JACK POSTS/MAIN BEAM
AIR INFILTRATION BARRIER
HEATING ROUGH-IN
INSULATION:
FOUNDATION WALLS INTERIOR R-
FOUNDATION WALLS EXTERIOR R-
FLOORS R- -
WALLS R-
CEILING R-
DUCT WORK,OR PIPING IN
UNHEATED PACES R-
(518) 761-8256
TOWN OF QUEENSBURY
BUILDING & CODE ENFORCEMENT 61441
742 BAY RD. , QUEENSBURY NY 12804
INSPECTOR'S REPORT: ARR 3'2 DEPART ) INT
17A47-
REQUEST FO INSPE TION RECEIVEDD:
NAME \� f� �C l a
LOCATION a_a o ( c9 -
DATE \k--- - 9 lg PE I A 1 C61/4-3 9
TYPE OF STRUCTURE: (J
RECHECK APPROVED
N/A YES NO
FOOTINGS/PIERS
MONOLITHIC POUR FORM
REINFORCEMENT IN PLA
THE CONTRACTOR IS R SPONSIBLE FOR
PROVIDING PROTE TION FROM FREEZING
FOR 48 HOURS FOLLOWING THE PLACE-
MENT OF THE CONCRETE.
MATERIALS FOR THIS PURPOSE ON SITE
FOUNDATION/WALLPOUR
REINFORCEMENT IN PLACE
FOUNDATION/DAMPPROOFING
BACKFILL APPROVAL
PLUMBING VENT/VENTSIN PLACE
ROUGH PLUMBING
PLUMBING UNDER SLAB _
FRAMING:
JACK STUDS/HEADERS
BRACING/BRIDGING
JOIST HANGERS
JACK POSTS/MAIN BEAM
AIR INFILTRATION BARRIER _
HEATING ROUGH-IN
INSULATION:
FOUNDATION WALLS INTERIOR R-
FOUNDATION WALLS EXTERIOR R- _
FLOORS R-
WALLS R-
CEILING R-
DUCT WORK OR PIPING IN
UNHEATED SPACES R-
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4
TOWN OF QUEENSBURY
BUILDING & CODE ENFORCEMENT
742 BAY ROAD12
QUEENSBURY NY 12604
(518)745-4447
- -
ARRIVE: /•r�4 DEPART: IIdSI':
FINAL INSPECTION REPORT — RESIDENTIAL
DATE INSPECTION EQUEST RECE VED:
NAME �'�' 4.4-1 '(C/4
LOCATION /3/ 449 Q/
DATE /v/2 �4. PERMIT 1 /b
TYPE OF STRUCTURE
FOOTINGS FOUNDATION BACKFILL FRAMING _
ROUGH PLUMBING _ SEPTIC _ INSULATION
FINAL ELECTRICAL WOODSTOVE OR FIREPLACE
N/A YES NO
CHIMNEY HEIGHT/B VENT/HE HT
PLUMBING VENT
ROOFING
EXTERIOR FINISH
DECK/PORCH/STE /RAI INGS
RELIEF VALVES!
FURNACE/HOT WATER OPERATING
INTERIOR TRIM/PRIVACY DOORS
FINISH FLOORS:
BATH/KITCHEN WATERTIGHT
OTHER FLOORS SWEEPABLE
OTHER FLOORS CARPETED
STAIR CLEARANCE/RAILINGS
SMOKE DETECTORS
BATHROOM FANS
PLUMBING FIXTURES
FOUNDATION INSULATION
GARAGE FIRE PROOFING
DOOR CLOSERS _
FINAL ELECTRICAL
SITE PLAN/VARIANCE REQ.
FINAL SURVEY PL T PLANT
}
OK TO ISSUE /O R C/C 149
(518) 761-8256
TOWN OF QUEENSBURY1611
BUILDING & CODE ENFORCEMENT
742 BAY RD., QUEENSBURY NY 12804
INSPECTOR'S REPORT: ARR/Ow DEPART INT
REQUEST FOR INSPECTII9 RECEIVED
NAME t!�/� Z//J%AY
LOCATION //• 0?.97 I
t f�` /DATE � C? PERMIT /v -63/
TYPE OF STRUCTURE:
RECHECK APPROVED
N/A YES NO
FOOTINGS/PIERS
MONOLITHIC POUR FORM
REINFORCEMENT IN PLACE
THE CONTRACTOR IS RESPONSIBLE FOR
PROVIDING PROTE TIOH FROM FREEZING
FOR 48 HOURS FOLLO NG T PLACE-
MENT OF THE CONCRET .
MATERIALS FOR THIS P OSE ON SITE
FOUNDATION WALLPOU
REINFORCEMENT -I PLACE
FOUNDATION DAMPPROOFIN _
BACKFILL APPROVAL
PLUMBING VENT/VENTS IN PLACE
ROUGH PLUMBING
PLUMBING UNDER SLAB
FRAMING:
JACK STUDS/HEADERS - T
BRACING/BRIDGING
JOIST HANGERS
JACK POSTS/MAIN BEAM
AIR INFILTRATION BARRIER
HEATING ROUGH-IN
INSULATION:
FOUNDATION WALLS INTERIOR R-
FOUNDATION WALLS EXTERIOR R-
FLOORS R-
WALLS R-
_CEILING R-
DUCT WORK OR PIPING IN
UNHEATED SPACES R- -
6, 7c h/if l - /4 7c
Date
COMMONWEALTH ELECTRICAL INSPECTION SERVICE INC.
(Consulting and Fire Inspection Services)
(Incorporated in the States of MAIN OFFICE:357 Elwyn Terrace, Manheim, PA 17545 • (717)664-2347
New York,Maryland,Pennsylvania,Delaware) 800-732-0043
LOCATION
Please give full arid accurate directions in order to avoid delay (:)(0 ....6,
(Use back of sheet if needed)
Desiring Certification of Approval, application is made for inspection of electrical installation in the mises
described below.On demand,applicant agrees to pay for inspection service in accord with schedule of c s.
PLEASE PRINT DATE i /6 -
Owner Vo/v i,.../.J.l,..PM 4- °" Type Bldg. [Lf! G ❑Other
Occupant N Building� Permit No.
€Job Location i DC E t City..Q.Lf.5.. Ain State .:.A!!;J'
O A
County L, g- I' Twp. Swimming Pool-New El Old❑
Owner's Address J/� Pool Permit No.
5.O irections to Job Site ' 't S At ''% /V 9' L)eJ LT 4 FT, 5fr1, O� ii Re
3{" tp�pplication For Rough Wiring IllFixtures❑ Service CIor 1.cf k'es AF.L��, F/2e
I'b d Work-New El Additionab❑ Bldg.-New El �Jld El Ready for Inspection
Fee Remitted / i Check Tr/Cash❑ Make Payable To C.E.I.S„Inc.
LIST ALL EQUIPMENT AND WIRING
NUMBER OF ROUGH NUMBER OF ELEC.HEAT-AIR CONDITIONERS-BURNERS-DRYERS-HEATERS-RANGES,ETC.
WIRING OUTLETS FIXTURES NUMBER TYPE OF DEVICE H.P.OR K.W. NUMBER TYPE OF DEVICE H.P.OR K.W.
SWITCHES MERCURY _
LIGHTING SODIUM
RECEPT. FLUORESCENT
ELEC.HEAT QUARTZ
MOTORS:H.P. 1/20 1/12 1/10 1/8 1/6 1/4 1/3 1/2 3/4 1 1-1/2 2 3 5 7-1/2 10 15 20. 25 30 40 50 75 100
MARK NUMBER
OF EACH SIZE
OTHER EQUIPMENT
APPLICANTS
SIGNATURE LICENSE# PERMIT#
PLEASE D( I I f U PHONE#
PRINTNAME `�//1r'y9'frAJ CA. (V 4
APPLICANT'S L/fZ T/1� G ♦ 1 1'1_�,//��1 NAME OF / A
ADDRESS /' TT 76 }�A✓K A. /T c., y UTILITY ( /y�„ ) '�
CITYSI u' AJ S /�/TL C5 STATE Aft ZIP CODE/2..O BE NOT F ED
ROUGH WIRING SPACE BELOW FOR USE OF INSPECTORS ONLY
OUTLETS AMP SERVICE PUMP
EQUIPMENT
SWITCHES HEAT OVEN
PUMP
RECEPTACLES SURFACE GARBAGE
UNIT DISPOSAL UNIT
MEDIUM BASE RANGE
FIXTURES
MOGUL BASE WATER DRYER
FIXTURES HEATER _
FLUORESCENT AIR AMP. RECEPTACLES
FIXTURES CONDITIONER
MERCURY VAPOR OR WIRING&CONTROLS FO,Fi.. BURNER FRAC.H.P.
QUARTZ FIXTURES _ VENT FANS
MOTORS:H.P. 1/20 1/12 1/10 1/8 1/6 1/4 1/3 1/2 3/4 1 1-1/2 2 3 5 7-1/2 10 15 20 25 30 40 50 75 100
MARK NUMBER
OF EACH SIZE
APPARATUS /oo A -
SC.INF : DATE INSPECTED RE- 0 p
IOC.
A,1`>l.1..f:7-, r/0 NOTIFIED POR- ¢ Z J,.,-1
FEE PAID
1f/
,,��rr�� TED v (''�
'�6 "q CON- TOTAL $/3,
TRACTOR
WORK INSPECTED OWNER CHECK NO. /f5 7
❑R.W. ❑SERV
❑FINAL OCCUPANT CHARGE
CERTIFICATE NEEDED AGENT CASH
❑YES ElLT. C.O. H.O.
T-0
TEMP CARD# DATE INSPECTOR
FINAL CARD# .
BP/9627 Rev.1/95 APPLICATION EXPIRES ONE YEAR FROM DATE.
WHITE/Office CANARY/Officer PINK/Inspector GOLD/Customer
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