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1987-655 x CER.'TIFrICA 1 �. OFC�CCLTI'AN+C�i' TOWN OF QUEENSBURY WARREN +COUNTY, NEW YORK marc1, ^ 3 , i9 'Date 87-655 This is to cerltiN that work requested to be done as shown by Permit No. has been carnpleted. This structure may be occupied as a Jute Family dwelling Ldcyarion Lot � Av n Stili�aiyzax+ (BI ..Bay Rd « ) Y.aymond J Sr.orms Owner By Order Town Board OrOW N OF QUEENSDURY 000 Building & Zoning inspector BUILDING PERMIT TOWN OF QUEENSBURY No. 87~655 WARREN COUNTY, NEW YOiRK PERMISSION is hereby granted to Raymond .7 . Storms A riz' OWNER of property located at Lot # 18 Bardin Subdivision (Big Bay Rd . ) Street, Road or Ave. r in the Town of Queensbury, To Construct or place a One Family Dwelling 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 RD #4 Box 554 O Big Bay Rd . p, Queertsbury , N . Y . 12801 2. CONTRACTOR or BUI LDER'S Name r4 rr 0 Same " m 3_ CONTRACTOR or BUILDER'S Address. t-' O r't 4. ARCHITECT'S Name Oo tFl !v to 5. ARCHITECTS Address FF p C C 6. TYPE of Construction — (Please indicate by X) l -6 ua (X) wood Frames S I Masonry I ) Steel l 1 ~o 7. PLANS and Specifications No 46 ' x 28 ' 41 " per plot plan , specifications and application including septic system and attached two car garage . ' $' Proms Use One—Family Dwelling roy w r- $ 5 . 00 C/O $ _ 115 . i30 PERMIT FEE PAID — THIS PERMIT EXPIRES Aprdal 1 , 19 88 @ lit 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.) f-; .q (1G Dated at the Town of Queensbury this 28th Day off Sept . 19 87 SIGNED BY _ ..,�' rsir' for the Town of Queensbury Building and Zoning Inspector TO BE COMPLETED BY BLDG . DEFT . aw n 1 Application No . .J wn o/ Q"eenj "ry Permit Issued 19 BUILDING and ZONING DEPARTMENT Permit Expires 19 Bay and Haviland Road, R.D. 1 Box 9$ Zoning designation Oueensbury, New York 12801 Variance No . _ Site Plan. Review A o . LP 'Z 4 J V J�SCU Approved by�-.-may'"' •7 iF {�'.41 F—'F�—s aN APPLICATION FOR , BUILDING AND ZONING PERMIT A PERMIT MUST BE OBTAINED BEFORE BEGINNING CONSTRUCTION . ANSWER ALL OF THE FOLLOvJING . The undersigned hereby applies for a Building Permit to do the following work which will be done in accordance with the description , plans and specifications submitted , and such special conditions as may be indicated on the Permit . The owner of this property ise � jeP . O. Address . Tel . �V- Property Location : � Acl Tax Map No . ,�/ / Street number or building lot. number Subdivision name ( if applicable) a�.+ THE PERSON RESPONSIBLE FOR SUPERVISION OF WORK AS RE S BUILDIN CODE IS : - L ,. d S Ne P . 4. Ad ress Tel No . am Name of builder _ Address Tel . Name of plumber Address IJ�) ++�`^ti Tel . �r _'� Name of mason --,r`—n '� ---�+ l"rll C _Address * ITel ' NATURE OF 'PROPOSED WORK ; ZONING INFORMATION : Construction of a new building A PLOT PLAN MUST BE PREPARED AND SUBMITTED , Addition to a building * drawn reasonably to scale and attached hereto , TAlteration to a building showing clearly and distinctly all buildings , � (no change to exterior dimensions) * whether existing or proposed and indicate all Other work (describe) set-back dimensions from property lines . Give street and number or lot number and indicate * whether interior or corner lot . Show location FOR DEMOLITION PERMIT , STATE: SIZE AND of water supply and location and configuration LOCATION OF STRUCTURES AFFECTED . * of septic disposal area . COMPLETE INFORMATION REQUIRED BELOW . Size of property k,cc--:� _ ft x ft _ Existing building € s S ft X ft . AA PROPOSED BUILDING AND USE : 1 v� Existing building ( s ) Use Size of new structure J446 ft Xorat ,r Foundation-pier/slab/crawl/partial/fu11 * Proposed building , distance from property line * ft (circle one ) I * Front yard 7� ft Rear yard_�1��'X^7� No . of stories (habitable space) ,� Side yards _ft and :R - ft Height ( grade to ridge ) _ ]$ ft . * If on corner , setback from side street ft if residential , no * of families / orne ANY INFORMATION No . of rooms ( excluding baths ) G• _ ` No. of bedrooms PRI RY BUILDING - No . of bathrooms One family dwelling Primary heating system W Two family dwelling Type of fuel Multiple dwelling / Number of units No . of fireplaces to be installed l * Permanent occupancy Will a wood stove be installed? An Transient occupancy Central Air conditioning? NCB_.— Business BUILDING STYLE, PRIMARY STRUCTURE * Industrial Other Ranch Contemporary Log cabin * If addition , what will use be? Raised ranch Mansion duplex Split level Old style 'Bungalow Other ACCESSORY BUILDING- Cape Cod Cottage Car Town House Detached garage/one car/ two car/ Colonial Row * two car/ car ( CIRCLE ONE PLEASE ) ttached garage/one cart Private storage building ESTIMATED MARKET VALUE OF .Other CONSTRUCTION INFORMATION ON BUILDING SPECIFICATIONS , ON REVERSE SIDE OF THIS SHEET , TO BE COMPLETED ! Form BPA 4/86 md•-VI .BUILDING PERMIT APPLICATION CONTINUED - BUILDING SPECIFICATIONS : Type of construction , wood frame , fire safe , etc . At � i"t3�trwQ Will any second-hand or ungraded lumber be used? If so, for what ? Foundation wall material ,IL( / e�/L Thickness //) ! { / �,�. ' 6-1tx - 2)2L 0 Depth of foundation below grade (to bottom of footing) 1Z I/ � Will there be a cellar ?�Ieated or unheated? Floor sq. footage �lI� 2 -+ sq ft Will there be a basoment . .. C� Will any portion be used as living space ?_ ( If so , what port ' � (Jsq , ft . - - Type of use? Type of roof - s oped flat/shed/other Material of roof Size , wood stu "'x , '" spacing—&__o . c . length � ' ft . .Toists ( floor beams } lst . loor ""X- spacing IL "io . c . span -ft . IAN Joists ( floor beams ) 2nd . floor FIX spacing— "o . c . span ft . Overlays (ceiling beams ) "X to spacing "o . c . span ft . Roof rafters "X IF spacing o . c . span ft . Roof trusses (pre- engineered) spacing I/ "o . c . span x'e-Vft . Exterior wall finish ? reC t 7 —Of what material? Interior wall finish If a garage is to be attached , descrx a materia s to be used for FIRE SEPARATION ; Is there to be an open5hg heltween garage and dwelling? iyli[_ If so will a Fire-rated door , enclosure , and self-closing device be provided?Will a flue-lined chimney be installed? Height abov roof ft . Depth of chimney foundation below grade If ft . Depth of fireplace hearth a2. ft . in . Water supply Municl-pa or private well w SEPTIC SYSTEM _ ce .from ANY private well ( including adjoining properties (A separate application is necessary for any repair or new installation of septic system) Town of A F F I D A V I T 'STATE Off' NEW YORK Warren County off Warren I swear that 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 oth r laws pertaining to the proposed work shall be complied with , whet40e2:7 ' s cified o and that such work is authorized by the owner . SWORN TO BEFORE ME THIS Signature _ _____ _ _ _______________ �Owxa agen arcnirect , contractor day of 19 Notary Public , Warren County , N . Y . * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * It SPECIAL CONDITIONS OF THE PERMIT : 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 following : 1 . Gross floor area 3 2� 2 . Type of heat ctacr 3 . Is the building mechanically cooled ? V%40 4 . Percentage of area of windows and doors A . Over 15 % Only 1 . U value of gross area of walls , roof / ceiling and floors o 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 ki B . Under 16 % Only 1 . R va e,> roof and floors exposed to ambient conditions _ 2 . R value of exterior walls 3 . R value of glazed area I 4 . R value of doors / 5 . R value of floors over unheated spaces Fa . R value of slab edge insulation - unheated slab 7 . R value of slab insulation -- heated slab S . R value of heated basement / cellar walls ( above grade ) 9 . R value of heated basement /cellar walls ( below grade ) 104 Type of insulation ../It C. C . Controls �0 1 . Thermostat maximum heat setting D . Duct Systems 1 . Is duct system installed in unheated spaces ? YES [ Nd) a . if YES , R value of duct installation �---�' b . R value of duct in other areas E . Piping Insulation +r 1 . Size of hot water or cooling carrying agent pipe 2 . R value of pipe insulation F . Service Water Heating � xr 1 . Performance efficiency. 2 . Temperature control setting maximum / G . For Swimming Pool Only 1 . Maximum heating V\ Telephone No . :Jq .. �T � ( pp cant ' s s gnature ) 94ye 19t of Qd�' 4tp APPLICATION FOR SEPTIC DISPOSAL PERMIT DATE MyC7 LOCATION OF PROPERTY FOR INSTALLATION �lr Owner's Name : -tAd f,44_C Telephone: 4,`.�r /t^_y}�� ��-- Address: JJ Installer's Name: -•+ _Pcn Alij Telephone: U Number of bedrooms (residential only) ..??ti, _ Total daily flow (compute @ 150 gal per bedroom) Topography: circle one Flat Rolling Steep Slope % of slope Soil Nature*. circle one: an Loam Clay Other / Depth: feet J Ground Water: At what depth? 49j feet Bedrock. or Impervious MaterWa. At what depth? � ? feet Percolation tests circle o not required required / rate thin. inch. Domestic water supply: circll--e one Municipa ell Other IF domestic water supply is a Well: Separation: 'Watersupply from Septic absorption ` feet PROPOSED SYSTEM.: Septic Tank 1190t)— gal. (minimum size: 1,000 gal.) TILE FIELD: Each Trench 41100 _ 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 M P O R T A N T ...Please...LIST NEW EQUIPMENT TO BE INSTALLED (over) Section II 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 Z.) 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, tile fields and/or drywells B. No system shall be covered before inspection and approval by the building Inspector. Failure to comply with this requirement may result in the uncovering of the system by the installer and a fine of up to $250.00. C. An approved copy of the plot plan shall be available on the construction site. Failure to produce said plot plan at time of inspection may result in an immediate work stoppage. D. Should unforeseen problems during construction prevent proper installation, alteration or repair of an approved system , a new proposal must be submitted to the Queensbury Building Department before further construction. I have read the regulations above and asgree to abide b3y the and all requirements of the Town of Queensbury Sanitary a ce. 7 Signatures�of responsible person: Date: J-4 Town of Queensbury Building and Code Department Bay at Haviland Road Queensbury, New York 12801 (518) 79Z-583Z SETTLED 1763 . . . HOME OF NATURAL BEAUTY . . A GOOD PLACE TO LIVE MIDDLE DEPA& G f irAE 7 MSP CT ON AGENCY, INC. Sao r4aduoe'''�►; iTgi _ i4�° Septem'bBr 2 1988 �* ri rred'a ',is approved as being in accord QL,ertlfle that try 4"IectriClkl,e4u1pment fisted has been uxa � . with the National Electri'$ l CQCie, al5piicable governmental, utility and ne AM10s. Ray 1 Y P,4Y7., W E .:.1 i.'ng � i3 StormId ' ,x = r nt * .y rt dd ; •. occupant: Same rn2 i �(r / �r is-ce ficats tlill�ftec4 ipment and instanation Inspected this �r 2. d 4c1d`�'.^` (yU''�'e'F18� ` �nf Va y dole Itidditkonat sfqui}lmeni isfl be in7roduoed Of anerations made to LOC&t1On: g • �9 e�lSlknq syslem this certlUcaw be nuit and raid. and eppkicatkon or k" t thle Aenc .mttinapectian should he fub 1 _G r F • C = I C @ ! t Ac le ; 200 �p" .: 'S Ff rV:LC tE " �y�y }} E`t{oldar of this cenHicate ahrwld PiiW*nt ssrne to hks property Insurance GrriBr �QLi1�7lF7BFl - ""r " "(agent or corn pony)of Sri dll"00Gl.CSrtiliGtiOn of Blectrioel SquiPmO'nl aPProrStl N l s f Ray Storm r r a , .r � o . 15 -019341 Applicant: Bid 'Bay Road ML �'� s Glens FaILIS , NY 12801' _6��„_ Forest Wu, 7" &L I-" _,Down o1 Queer+ skury lrIV% BUILDING and ZONING DEPARTMENT �E © gay and Haviland Road. R.D • 1 Box 98 Queensbury, New York 12801 BL) I LD I NG INSPECTOR ' S REPORT NAMEt J��D/2JFf*�3 LOCATION c Crate Per fSr /, m.-t Lao 0I * APPROVED - YES NO Footing/Pier Forms Foundation Waterproofing Backfill Framing Roofing Siding Masonry venee Rough plumbing Relief valves F.xt . 1'orcY�es Finished Floors Interior Trim Stairs & Railings Cellar Drain Tile Concrete Floors Pliag . Fixtures Gar . Fireproofing X LDoo. Closers Smoke Detectors Chimney ILPLSULATION Foundation Floors Walls_ Cell in(l INAL 1•:L1.CT YCAL, I13SF'ECTICIN RIVEWAY AP ROVAL� F�na.l Buil ng Survey Next scheduled inspection (call whert ready ) Remarks- A � / Lluilding Inspector GJ 8Fa rnd-vl ajEPARTMCm waSPEG i mN AGENCY, INC5� +� � Lc • {� National Headquarters 9 V J 900 Haddon Ave., Collingswood, N.J. 08108 APPLICANT r r Date: City, Town or Township - County ,ll 10 State Location/Address of Locaked in Rural Area - Please Attach Directions) Pale # Owner Permit # Occupied As Building: New�� Old Occupant _ .._ . . .. Work Area in Buildin Floor #, etc.) : App. for: Wirin Service El or: Ready for Inspection : Fee Remitted - $ Cash F1 Check El M.O. E3 Make Payable To : M.D, I.A. Soo 750 1000 1x5o 1500 1i5a xoao xxso z50o 2�sa 3a0a Number of Rough Wiring Outlets -- - - Elect. Heat Switches _ -C1�� Amp. Service Surface Unit Dishwasher Range Lighting Water Heater Air Conditioner ___Dryer Pump Receptacles J g:;� �- - Oven Garbage Disposal " Wiring and Controls for Burner Number of Fixtures -Amp. Receptacles Fractional H.P. Vent Fans Other Equipment: MOTORS H.P_ 1/2 1/12 1/30 1/8 1/6 1/4 1/3 1/2 3/4 1 lilt 2 3 5 7Yt 10 15 20 25 30 0.0 50 TS 100 Mark Number -- . - .. . _ _ .. _. _..- _ - . _ . . .. of Each Size Applicants Signature License # Per nit # T/A Ca, )( I'"*10%. . _ Utility . o (NAME) O ICE LOCATION Applicant's Address: A02 ale - (City) (State) (Zip) Service Request # 211 Electrician : _. Phone'# - -- rra�yy {,p}Q r ' r DATE RECEIVED: � - - - --- - -DATE INSPECTED: Correct Location : Same as Above 0 or: - Red Notice Label Q Rough Wiring Outlets Surface Unit Oven - Switches - " Range Garbage Disposal Rece tacles Water Heater Dishwasher Fixtures Air Conditione;& Controls Dryer Amp. Service Equipment - - Burner, Wiring for Amp. Receptacle Amp. Service Conductors . Pump Vent Fans MOTORS H.P. 1l20 1/12 1/30 1/8 1/6 1/4 1/3 1/2 3/4 1 Iva 2 3 5 7vt 10 J15 20 25 30 40 50 75 100 Mark Number. ..- _ - _ -- • - - - - - of Each Size " . _ . .. . . _ . _ ...- - .. soo I 7501saoo 1254 15ao 1a5o 200a xxso xsaa rya S0a0 Elect. Heat ^.w x v « F V s ; BUR ;, uC �., i w PAID „Y Rma FEE • FEE P ;a RW Progress: Inc. LKD Q Contractor ep 0 CFT Violation : Work Comp. Q Inc. CASH Q LIA Owner Fee CHK CJ L/A C:: ` Due MO # 0 . IPA � � o e7 __ _ - - .Municipal _.__ _. 1hlV Applicant Dier Other Side 0 LJtiltty owner ' Cut in Card []} .Tempi# 1 ;F Date " .. ,�� - ,,.y Iy �Tj F �y, �,,..• _ INSPECTORS SIGNATURE V1 .. '-�Flnal ,#.]y�'L I• jjLL df".� / Date . . �9: nL. . C,,7 °C:i'. i[ .. . .. APPLICATION FORM NO_"2540 EF_ 11/86 - • , . . • .^s --: ;.; 4 Vfk., J iA A _lawn oueenslhetrt BUILC)ING and Zf]NIN C]EPARTMEP4T gay and Havifand Road. 8 0 I Box 98 Queensbury, New York 12801 BUILDING INSPECTOR ' S REPORT NAME LOCATION �r�L+ Date 4 crS fc — Perm t No APPROVED - YES NO Footing/pier Forms Foundation Waterproof ing Back£ill �aming Roof ing Siding sonry Veneer ugh Plumbing ,, lief valves Ext . Porches Finished Flo s Interior Trim Stairs & Rani. qs Cellar Drain Ti Concrete Floors 171bg . Fixtures Gar . Fireproraf ing Door Closers Smoke Detector's Chimney INSULATION Foundation Floors walls Ce i l inc} INSPECTION FINAL ELL:CTRICA ORIV'EWAY APPROV �T Final Building; i Spec (call when ready ) Next ,cll seduled f� Pr Remarks- 2c C { CLx IE� ►"GC t)'j7 ' fni f4,cw1 Bui1 ing Inspec ar G/B6 and-vl BUILDING and ZONING DEPARTMENT Bay,nd Haviland Road, R. D. 1 Box 98 t 0ueensbury, New York 12801 SEPTIC DISPOSAL SYSTEM INSPECTION NAME A4 LOCAT I ON-,,ice t�.L��� DATE L RMIT NO . U ~ SCTL TYPE - Sand - Loam - Clay Percolation Test Required? YES - NO Percolation rate - Min/Inch TYPE of SYSTEM : Absorption f eld , total length Length of ea trench Depth of tren hes Size of gravel -- SEEPAGE PITS4N er of) Size- ft. X ft_ Gravel size PIPING : S ]Bldg , to tank Tank to list . box Dist , box to field/ openings sealed? Y No Partial LOCATION/SEPARATI Foundation to an �t- Foundation to abs rptian ft - Absorption to to line ft- Separation of p ' ts ft- LOCATION OF SY CtI PROPE TY (circle one) Front - Rear - Left side - ht side - CCMMENTS CI SYSTEM USE APPROVED(!YESD No Build n nsp+ector 01/B6 and vl _._../own 01 Queenigury 11 ,187 BUILDING and ZONING DEPARTMENT gay and Haviiand Road, R. D. 1 Box 98 C2ueensbury, New York 12801 SEPTIC DISPOSAL SYSTEM INSPECTION NAME LOCATION e 7 DATE /! cF /`' PERMIT SOIL 'TYPE - Sand - Loam - Clay - Percolation Test Required? YES - NO Percolation rate - Min/inch _ TYPE of SYSTEM : Absorption field , total length Length of each trench Depth of trenches Size of gravel SEEPAGE PITS{lumber of) _ size- ft. x Gravel size PIPING : Size Type BldgII, to t nk L Tank to dis box Dist. box t field/ openings sea ed? YE No artial LOCATION/SEPA TI I ft. Foundation to tank f t. Foundation to bsorptiO c Absorption to 1 t lin t , separation of P is ft. LOMTXON PROPERTY (circle one) Front - eYS - L side - Right stde� ,- CCNIMENTS � �r �� �,, 1 U IMM SYSTEM USE APPROVED YES NO Building Inspector ol/86 and vl �.lo utrt or� �u ee rt s tt r c� BUILDING and ZONING DEPARTMENT Bay and Haviland Road, R.D- 1 Box 98 Queensbury, New York 12801 BUILDING INSPECTOR ' S REPORT NAME ✓ ter( LOCATION tX �Y G[ fr Owl, Date„___- Permit I3o . _ APPROVED YES NO Footing/Pier Forms��___ > ,'Foundation waterproofing 6ackfill Framing Roofing siding Masonry Veneer Rough plumbing Relief Valves Ext , Porches Finished Floors Interior Trim Stairs & Railings Cellar Drain Tile Concrete Floors Plbg , Fixtures Car , Fireproofing Door Closers smoke Detectors Chimney INSULATION * Foundation Floors Walls Ceiling FINAL 'ELECT CAL INSPECTION DR1V'EWAY APPROVAL Final Building Survey Next scheduled inspection (call when ready ) Rema�� Building Inspector 6/8Fi and-vl OA � ,� 1 BUILDING and ZONING DEPARTMENT Bay and Haviland Road, R.D. 1 Sox 98 'r Queensbury, New York 12801 ILDING INSPECTOR ' S REPORT ,AME LOCA, T I ON / s, Date / Perfni. t No . ,r APPROVED - E NO ooting/Pier Forms Foundation Waterproofing Backfill Framing Roofing Siding Masonry Venee Rough Plume n Relief Valves Ext . Porches Finished Floors Interior Trim Stairs & Railing Cellar Drain Tile Concrete Floors Plug . Fixtures Gar . Fireproofing Door Closers :Smoke Detector Chimney INSULATION - Foundation Floors kk Wal1. s Ceiling FINAL ELEICTRICAL INSPECTION DRTVEWAY APPROVAL �� Final Building Survey Next scheduled inspection ( call when ready ) Remarks- TO C4 Liuiiding Inspector 6/86 and-vl MIDBLE *PART PIT IN$PECT#NN "6NCYr- INCa National Headquarters 900 Haddon Ave., Collingswood, N.J. 08108 Date: `tW zA"5 10k=up1ed ^s ty, Town or Townshi =( a c / 1 County WA r re, -01 State ocation/Address a 6 # 1R�. 02 f�l1 � u r - .Al, (if Lo eid in ural Area = Please Attach Directions) Opole * 5r^ Permit' # Building: NeWT Old Q Occupant Work Area in Buiidi Floor #, eto;.>: for: WiriQq Service MI or: Ready for Inspection : Fee Remitted - CashC3 Check M:O. Make Payable To: M.D. I.A. 15" 1 780 14,Wl125a ;5M 1750 20a4 225a 25aa 275a 3000 Number of Rou .h Wiring Outlets Elect. Heat. ' itck LLLiight ng � Amp, Service Surface Unit Dishwasher :._.,—Range Rf of tacles ____tom__.__... Water Heater Air Conditioner Dryer Pump P Nurnr of Fix u Oven " . Garbage Disposal Wiring and Controls for Burner : Amp. Receptacles �- Fractional 1J.P. ent Fans Other Equipment: 3 MOTORS H.P. 1/2 1/1 1/10 1/e 1/f 1/d 1/3 1/2 3/4 1 1V1 2 3 5 74a 10 15 26 1 25 1 30 40 50 75 100 Mark Number of Each Size ,Applicant's Signature.. License # , hermit # T/A Utility:llty: i, ApPlicaelk's" � NAME CIFFJCE LOCATION) (City) (State) (Zip) u' Service Request # Phone # ElectriGiani; DATE RECEIVED. DATE INSPECTED: 7Receptacles Location : Same as Above 0 or: ' abelough Wiring Outlets Surface Unit Oven witchesRan a °Garba Water Heater Dfishwasher Fixtures. . . . .. . . . ''Air Conditioner Dryer Amp, Service Equi inept %Burner, ring i&•Contr� 's or '` Amp:. Cat lei' Amp. Service Conductors Pump 'Vent Fans MOTORS H.P. 1/20 1/12 140 1/a 1/s 1/4 1/3 1/2 a/4 1 1+� 2 3 5 7$h 10 15 20 25 30 40 50 75 1157 Mark Number of Each : Elect, Heat sso 750 loco 1250 1-"O 1750 ;qpa 2250 25ua 275a 3000 r� RW Progress: Inc. LKD 0 Contractor !s; Q CPT Violation : Work Comp. Inc. M L/A Owner CASH L/A V Fes CHIC # _ Due MO #. . IPA _ Municipal - fNV # Date: Other Sidela !] IIItY Orivner LCutCard �] Temp # Date P t L12 _ . . [� Final # Dater ' 9MS12fr1'CIRSl51ANRi URE APPLrCATION FORM F40. 25 'Et '1 Y,/>! • . .. - _ - - _ .. . s - - ,40 vie o0at OP 6109 sad