1989-649 v ♦ . .. ,w"I. _ ..0 ' x }' _ e. —"9S
I
I { 1
f A'TE 0 OCCUPANCY
CERTIFICATE i
TOWN OF +QUEENSSURY
WARREN COUNTY, NEW YORK
Lip 899649
t This is to certify that work requested to be done as shown by Permit No.
has been completed.
k This structure may be occupied as a S i rig l e F and l y Dwelling
i
Lot 115 Oak Tree Circle --
C)wne! Fnrrfct Wand 9-inmpc
Sy Order Town Board
i
TOWN OF QUEENSSURY
Director of Bldg. & Code Enforcement
BUILDING PERMIT '=
TOWN OF +QUEENSBURY No.
WARREN COUNTY, NEW YORK
1
PERMISSION is hereby granted to Forest Wood Homes s;
OWNER of property located at Lot 115 flak Tree Circle Street, Road or Ave.
in the Town of Queensbury, To Construct or place a _ Single 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 Oueensbury Building and Zoning Ordinance.
-n
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t. OWNER'S Address is m
[.n
HC-02 Box 286P
Warrensbury , N . Y . 12885
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2. CONTRACTOR or BUILDER 'S Name
T
Self
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3. CONTRACTOR or BUILDER'S Address
Same
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4. ARCHITECT'S Name
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5. ARCHITECT"S Address .s
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6_ TYPE of Construction — (Please indicate by Xi
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)(I,g I Wood Frame f ! Masonry 11 Steel I i r'
Fr
7_ PLANS and Spacif i cations
No, 26 ' x 28 ' Single Family Dwelling as per plot plan , specifications ,
and applciation , including septic , attached two car garage and
waty
8. Proposed Use
w
c.
Single FAmily Dwelling
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$ 279 00 PERMIT FEE PAID — THIS PERMIT EXPIRES March 1 1990
(If a longer period is required an application for an extension must be made to the Building and Zoning inspector of the r
town of Queensbury before the expiration data,I
C
Dated at the Town of Queensbury this 17th Day of a August 19 89 r
fr
SIGNED BY for the Town of Queensbury
Building and Zoning inspector
QUEENSL7U]2Y APPI. ICATTON FOR BUILDING AND ZONING PURZti(IT
_ .._..__r ._......
Pare-
Recriev ed S- - / TOWN OF QUlvEWS8URY
�s Rev. tewctiftp
> r
x Free Pa Ld ,Q ` a r AUG 4 158
BUILDING AND CODES DEPART1`'tT=1`fI' Date Iaaued BLDG. & CODE DEPT,
13AY e4nd ffAVIL.AND ROADS RD I JJOX 9c3 / 4rj �^j �C� 19
pUEENSQURY, NE[iI YfflK 12804 Pe nxrwt No . +v r [ Y
To7 . ( 518) 992-5832 Ext •20A'
.. k 'k ! k * M •li ik I k * w MI * Y" 14 Y * i. 7" * k * x >A 71 7" ♦ k a ■ k s }1 X k
A PER?11T MUST Do OBTAINED BEFORE BEGINNING CONSTRUCT1014I NO INspECTIONS
WILL BE MADE UNTIL APPI- ICANT HAS RECI" IVE- 1) A VALID BUI LDINC PERMIT .
All applicable spaces on this application znust be completed and the
&`Ipxature of the applicant must ap car on the reverse side of this sheet .
ft 7k it ak
The owner of this property is :
1' . O . Address
'PAX MAP NO
Property location
. /
teas there been any split of this property since October 1 , yes no
if yes , Planning Board Review is necessary .
SUBDIVISION t1AMlr , IP APPLICABLEci2. LOT NO .
The person responsible for supervision of work as regard , Building Codas is :
P . o . ADDRESS 't'� L . Now
NF� rt k U
/ ` ri' i'�`i Tel c� J ' -`'
tJame of builder I' c J - , ;: . ., Address Tel
14;A11e of Plumber E' T,<3clress k. ,
Name OL r�kai SC]n } ? ^ '.:i rTK Addra5 +! y�` W R L ] is - < 1 "TfFil � J 1 r 6 }
is J
( IATURE OF PROPOSED %ro I.K - * Z MINING INFOlthIASI' ION ( Offlccy use onlV )
fr'C_nn� truCcion of a new building � BONING D12SICNATION OF PROPERTY
ltiddition to a building # PERMITTED PRINCIPAL PERMITTI L1 ACCESSORY
A) cur:,cicsn to :► ljuilding '
REVIEW REQUIRED - PLANNING BOARD ZONING BOARD
� ( rro Ctr.rru] w to .:xr . rior ciatncn : ions )
OLLVr work (.fie_crik-)0 ' SITE PLAN REVIEW # APPROVED DATE
o
k VARIANCE 0 APPROVED DATE
GROSS AREA Or PRODPO5BD% STrtUC if, URR .
Remarks :
1st floor
2 nd Floor-- S q f t . CDf4P [.L '1'f INl'Qs:i u►'1'1(]1rl irf rtu ] StliU ftr f.U4� .
, y -
sire of prolsurty
Other Floors act f c • Exiting buil.li.rroj ( u) 7[ rc .
( not cellar or basement ) jW
TOTAL FLOOR ARRAS L r �1 s4 € t * 1:xiCil�g buildint2 W U":
i* kr : of new structur. �2 f t X Pt
l'oLu daL ion-pier/slat/crawl/L)o4rci:al lull 1'rolsos�d builaing , di .r3i+urcy line
:: cance horn L
tuircle one l ,r Front yard 3 �7 r1C [tear yard " ft
Noo of stories (hubicable rpac+e) w Side yards iS ft and1� ~' it
HoII C ( <Irade to ridgL: ) • i ft ' If on corn.: r , ; ttuback lfrosa side street cc
It' rasiduntial , no , of fr4milies I
Hoo of room*, ( oxcLuding b:ath:; ) r, OCCUPANCY INFORMATION
t1oo of bodrooaa:; 3 r
0 pRIMARY LsUILDINC -
Nov OX bachroouu.; � I_: Onc family dwelling
i"rizrury t}uatiaria sy :: r . ur d a I' e- ; Two f:.+rnily dwulliny
Tylsu of Euel_ c! � - r[ultil�l.: awcllinc) / Number of units
No . of fireplacwz; tooIs i nseu114d I'r:rtnanG nt occuP:a,cY
Will " wood %;LOVQ bw illuC..:. 11wd? AV ` '1"ac�rr :iwrrc occuLlarrcy
L•untrul Air ear4�titiwn i rrg'=... - " '� liu«:inc �a
Ruli.DING STYLC, PRIMARY STRUCTUR.0 lncluf;trial
Othcx
t::irrch Cont.:rr�i:c+ruYy LC,n calsin 1f .addicior; , wk&"c will u::y bu7
r;.... i ::ucl ranch at:anaicar Dul�lux ""
Jf>lit 14v&1 old arylo 1ru1ry... 1ow
C.:.P. _Crrd Cott ir1. Oclwr a ACCL35ORY UUILDI[JG^
Ccituniu .> sew 'sown House r lrrrtachacl y:rc;,gcloncr curl two c�/� car
CIRCLE ONE PLEASE
) ' Attached g:xragw/orle Ca two car CaL'
• w k M . w s k • a a. k x : s ■ * Prlv" Ce scor"ge building
t : '1' IHA7" lip NAR1: r'1' VA1_ U #'_ Of ' ~�0r.h
7NC'oRFtATION ON nUTLaTNC SPrCIPTCATIONS , ON Ftti VUnSE SIDE OF T11IS CttEET, ojIoQ BE COMPL7~reDf
Form DPA I0/88 VI
BUILDING PERMIT APPLICATION CONTINUED -
BUILDING SPECIFICATIONS :
Type of construction , wood frame , fire safe , eto .
Will any second-hand or ungraded lumber be used? If so , for what ? r
Foundation wall material Thickness
Depth of foundation below grade ( to bottom of footing )
Will there be a cellar ? NHeated or unheated? Floor sq , footage sq ft
Will there be a basement.? VVIwill any portion be used as living space? k13
( If so , what portion? sq . ft . - - Type of use?
Type of roof - Taped flat/shed/other Material of roof
Size , wood studs " X spacing "o . c . length £t .
Joists ( floor bears )- 1st . floor G "X i _1 spacing r i, "o .O . C . span r.;) ft .
.joists ( floor beams ) 2nd . floor "x spacing ! � "o . c . span--- ' ft .
Dverlays ( ceiZing beams ) NIX spacing} " o . c . span ft .
Roof rafters "x it spacing o . c . span ft .
Roof trusses (pre- engineered) spacing " o . c . spank -ft .
Exterior wall finish •' �Of what material ?
Interior wall finish .:= t .!. ,.' -; ,
If a garage is to be attached , describe mate ials to be used. K;r FIRE (SEPARATION :
Is there to be an opening between garage and dwelling? , If so will a `ire- rated
door , enclosure , and self-closing device be provided? -
will a flue-lined chimney be installed? I Height abcs"ve roof T ft .
Depth of chimney foundation below grade ft .
Depth of fireplace hearth ft . in .
Water supply - Mw��rcipal r private well _
SEPTIC SYSTEM _ Distance from ANY private well ( including adjoining properties ft -
(A separate application is necessary for any repair or new installation of septic system)
D E C L A R A T I O N
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 warp to be none oil the described premises and
that all provisions of the BUILDING COME, TILE ZONING ORDINANCE., and all
other laws pertaining to the Proposed work shall De milli ,d with, whether specified
or not, and that such work is authorized by the owner;
Signature ^r
Owner,; Oner's agent , architect, contractor
SPECIAL CONDITIONS OF THE PERMIT :
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
2 . Type of heat ✓ -' :. r
ti
3 _ Is the building mechanically cooled ?4 . Percentage of area of windows and doors D
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 heated ? YES NO
a . R value of insulation
5 . Type of insulation
B . Under 16 % Only
1 . R value of roof and floors exposed to ambient conditions _
ri J
2 . R value of exterior walls 1
3 . R value of glazed area
4 . R value of doors
5 . R value of floors over heated spaces 1 "J
6 . R value of slab edge insulation - unheated slab
7 . R value of slab insulation - heated slab
so R value of heated basement/ cellar walls ( above grade )
9 . R value of heated basement / cellar walls ( below grade )
r
I C
100 Type of insulation
C . Controls c
1 . Thermostat maximum heat setting )
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
1 . Size of hot water or cooling carrying agent pipe
2 . R value of pipe insulation
F . Service Water Heating
1 . Performance efficiency r�
2 . Temperature control setting maximum
G . For Swimming Pool Only
1 . Maximum heating
Telephone No .
( applicant ' s signature )
toWN OF QUE ENS 13LyrY
APPLICATION FOR
SEPTIC DISPOSAL PERMIT
U ! n ^f7
DATE 'Gy �1 # !
LOCATION OF PROPERTY FOR INSTALLATION
Owner's Name* � . � : +-, ? r.' Telephone: � ;Y� '' 14
Address:
Installer`s Name: ,a/; 1 l 1 ';'! Y , ` Telephone:
Number of bedrooms (residential only)
Total daily flow (compute(-�!a 150 gal per bedroom ) `T
Topography: Circle one: (Flat Rolling Steep Slope % of Slope
Soil Nature: Circle ane an Loam Clay Other. /Depth : Feet
Ground Water : At what depth ?Feet
Bedrock or Impervious Material: At what depth ? 6 Feet
Percolation test: Circle one "not require required rate min . inch.
Domestic water supply: circle one: lunici Well Other
I€ domestic water supply is a wel
Separation: Water supply from septic absorption feet
PROPOSED SYSTEM : Septic Tank gal. ( minimum size : 1 . 000 gal. )
TILE FIELD : Each Trench .�S_C3 feet/Total system length C� 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 nd agree to abide by these
and all requirements of the Town of Queens ury Sallitary wage saI .Qr.dinance.
SIGNATURE OF RESPONSIBLE PERSON: }: : . c
DATE :
L
OVER
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 plat plan showing :
1 . ) the proposed location of the system
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 ranks , distribution boxes ,
tile fields anJ /or drywells
B , No system shall be covered before inspection and approval by the
lsuilding Inspuctor . Failure to comply with this requirement may
result in the uncovering; of the system by the installer and a fine
of up to $ 2150 . 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 installa—
tion , alteration or repair of an approved system , a new proposal ;oust
he Submitted to the Queensbury Building Department before: further
coinStruct ion .
Town of Queensbury
BUILDING and CODES DEPARTMENT
Say and Haviland Roads
Queensbury , New York 12804
row
MJDDLE DEPAR7J� ENCY, INC. �{ ly/�I�J
�C� rtifie that ,$ "�. __.■ ', oetta May 2030 1990
with the National EieCt !•-e4uiF►rttent listed has been exec a
Q :aFAlle$ble governmental, utility and -A" r pproved as hung in accord
C)wnar: Forest Wood fa!y f' dy , S.
Single Farm /
Occupant: f I f P i4e x4 i
Location: Lot 115 Oak BI� tai l Q s
additional
uipmem and insranmtion ins
Equipment; 120 outlet ,BYO" exte. a system
I �,r�nr an s old
pC a pia L+ le . . q exiaTing system Ihi c �c it he introduced or ahem lions mado to
/� 1�inaPaciion should be au'UMitt A ll�o�lujF'I�, and roiA, and application fnr 200 Amp Service q' tpp l i4tneeis ; i{{VV�a (V Solder of IN ce plNcala shyG�ld Y Men".
�..� {agent or comPaiyy} aeeritl... nr same !'� nis Properly insurance carrier
s8 specified y / ertificarian of electrical ep uiprrienf approved
J
Dave Iiodsea is
Applicant. Tenth Avenue
Hudson Falls , MY 12
___. . a. 16-028444
TdIVN OF QUFENSBURY
BAYrly LAND CODES DE'PAFt?MENT
C3CIEENSBUR-Y ROADS
TL LEPHONE f NEW YORK -1.280,V, /
528l 792- 5832
UILDING INSPECTOR ' S RrPoRT
REQUEST FOR INSPECrrO
NAME N RECESVED
/� ----:
#
FODTr+VG� j,�ERs APPROS ED
Movo.L.r ' s Na
THxC PouR FORMS
FDU?VDA?1-01vPROOFIIVG
CKPTZZ APPROVAL
ROUGH P�'MB2NG
FRAMrNG
EZRCTRIC ROUGH_3N
INS Txc>
FOUN -� -"_ --
DATxo
FLOORS
�✓ALLS
�rC ZLrNG
t z INSPECTION
CHIMNEY HEIGHT
ROOFxNG
sxDr)VG
E'X^`ERNAL PORCHEsr
STAIR,S,CLEARANCE
PLUMBING F IT'S-----�_ -- _
.TN7'ERIOR T EF V E
F 2X7UR RE AZV
RSM/P �- Y ALV
I N-rS rj D F VAC
I� � OORS "
GARAGE FT
DOOR CLOSER +� I NG
SMOKE DETE
FINAL ELECT Rs
FINAL ApPh' CAL xNSPECTION '�
A L OF CONS TRUCTxO
A SxGNE
CERTIFICATE of OCCUPA ryCY
OBT.iIIVE FROM THE BUIZDxNG DVP
TFlESE EMI,gES RE ST BE
A
OCCUPIEDf ARTM T BEFORE
RENARS »
----
T(31YIv OF cNDuErsuur
BUTLD-LNG A CO17ES DE'PRRTME'NT
$AY & HAVTLA1yD ROADS
QU$ENSBURY. NEW YORx 3280,4
TELEPHONE (518 f 792-58.32
J3uILDING INSPECTOPrS REPORT
REQUEST FOR ThSPECTION RECEIVED NAME ;,P�
n ---_-____
Lcac.�TICtN11,16 ., G,
DATE
PERMIT #-
APPRpb•EIj,
F�7T2NG/PIE'RS YES NO
MoNozl-7V r rc PouR FORMS
FOUN j?'I171y/Da ugn,p'ROOFTNG
BAG`xF'ILL APPROVAL
'ROUGH PLUM.B.LNG
L-�M?NG
B7+E�fiRSCA r� G)YGN,
'C�sULAT?pNr
FOUtorDATTON
FrJOORS
WALLS
CEILING
FINALAl' 1p
TNSP�T
CH1 MNEY
R+OOFTNG H7sTGHT
--
SYDTNG /
EXTERNAL poRCBEs/STEPS /STAIRS-CLEAR=tNCg a; RAT ---�- _-__
PLVMBTNG F IJ{TUBES
INTERTpR i TRIM p /REL EIa A L�4 t•E'-�--
F'TNTSHED F LOO 22� VAC DOORS
GARAGE 4FISREPRpC7FINr +
DOOR CLOSER (SJ
SMOX_& DETECTORS 4,
FTNAZ ZLECT'RTCAL r T "'
FINAL APPROVAL SPECTTON
O , CONSTRUCTzo,ty —'
A SIGNED CERTI
OB+�ATNED CAT_& OF OCCUPANCY
THESE FROM HE BU-TLDSNG V MUST $L
PRE11 MTSRS ARE O EPARTMENfi $EFORE
IIIII
CCUPTED!
RE xs:
TNSP OR
TOWN OF QUEENSBIURY
BUILDING AND CODES DEPARTMENT
BAY & HAVILANb ROADS y' 7
QUEENSBURY, NEW YORK 12804- /TELEPHONE (5181 792-5832
BUILDING INSPECTOR ' S REPORT
REQUEST FOR INSPECTION RECEIVED
NAME v
LOCATI01y
DATE
`��--•-----_ PERMIT
APPROVED
FOOTING/P.TERS YES NO
MONOLITHIC POUR FORMS
FOUNDATIONfDAMP-P, F-I
KF'ILL APPROVAL
UGH PLUMBING
LMING
ELECTRICAL RO GH-SN
INSULATION:
FOUNDAT?ON Ip
~
rZOORS
WALLS
2.
CEILING
FINAL SNSPECTION:
CHIMNEY HEIGHT
ROO- ING
SIDING
EXTERNAL PORCH /STEPS
STAIRS-CLEARA117 E & RAz r,�,S
X'.IvG FIX
INTER RES/RE -rrp VALVE IOR TRI /PRIVACY DOORS
FINISHED F ---
GARAGE FIRE ROC7F'.�T- NG
DOOR CLOSE (S) -
SMOKE DETE TORS
FINAL ELECT ICA INSPECTION
FINAL APPRO AL or CONSTRUCTION
A SIGNED C RT.IFICATE pF
OBTAINED F4*0M THE BUS OCCUPANCY MUS2� BE.
THESE PREMISES A LDING DEPARTMENT BEFORE
RE OCCUPIED!
RL'MARKS:
1
r..
INSPECTOR
TOWN OF 'QUEE'NSB[URY
HUXLDING AND COPES DEP
SAY 6 FiAYILAND ARTMENT
OU
EENSI3URY ROADS
TELfi'+ti'11ONE NEFV PORK I280¢
(518) 792-58.32
BUILDING INSPE("TC3R ' S REPORT
REDUEST FOR - NSpVCT2C]N RLCL IYEb
!NAME
DATE
4PERMZ �i
APPRO ED
L �INGIP ER a YES ND
MONDLITIIX POUR FORM t
FOUNDA?"r0 DAMP-
[r.�ACKFrLLOOFTING
ROUGH p VA
FRAMrNG .'
ELECTRICAL GhT,_TN .
rNSI1LAq+rON: � �—�-
FOUNbA '--
4FZ004RS
WALLS
'CEIL rNG
FINAL rNSPECTr
4^ff1-MNEY 11ErG
R00FZNG
SIDING ....--
EXTERNAL pp
S27AIRS-C�r N /STEPS
F'I.L7M8�' NG F RArLB
Z'NTE4R,r0R TUR IRELIEF VALVE
IM/PR YACY DOORS
FrNISHED LODRS
GARAGE F RAI FIN
DOOR C SER (S)
SMOKE ETECTORS
FrNAL ECTR1rCAL IIVSPEC Ojy
FINAL PPROVA L OF
CONSTR TION
A SXGNED CEh72vrFrCA2j
E OF OCC ANCY
DETAINED FROM 2711E BUILDING p MUST SE
27ffESE PRL7MrSES ARE OCCUpXeD r. AR271hENT 13RPORE
REMARKS:
K
17TY)
101VN OF QUEENSBURY
BUILDrNG AND CODES DEPARTMENr
BAY & HAVILAND ROADS
QL7EEI4LSBU17Y. NEW YORK 228ok
TELEPHONE (.5I8) 792-5832
BUILDING INSPECTOR ' S REPORT
REQUEST FOR INSPECTxON
RE'CExVED
DAME
1OCA2'rC3N / f
DATE #
APPROVED
�/ tJOT2 NG/P tER S YES NO
MONOLrTHrC POUR FORMS
FOUNDATIONfDAMP-PROOFING
BACKFILL APPROVAL
ROUGH PLUMRZAVG --_
PRAMrNG ----
ELECTRICAL ROUGH�rN
xtvSULArxON:
POUNDATxoN
FLo>RS
WALLS
CErLrNG
FINAL r1VSPEPcrroN:
CHrMNEY HExGHT
ROOFING
srbrNG
EJCTERNAL PORCHES STEPS
STAxRS-CLE.ARANC
PLUMsrIVG FxxrU & RA-TZ s
xNTERIOR TRrM '/.RELIEF VALVE
FrNxSHED Fes/ RIVACY DOORS
GARAGE FIREpR+ FING
DOOR CLOSER{
SMOKE DETEC RS
FINAL ELECTRrC L XIVSPEMCTZON
F*ZIVAL APPROVA £� OF CONSTRUC"TIO1y
A SXGNED CERTxFxCATE OF
OBTArNED FROM THE OCCUPANCY MUST BE
THESE PREMISES H-v BUxLDING DEPARTMENT ,BEFORE OCCUPIED!
REMARKS:
x IS ECTOR
._.I'ou+n v� �ueerrshurt�
BUILDING and ZONING, DEPARTMENT
Bay and Havifand Road, R. D. 1 Box 98
Oueensbury• New York 12801
SEPTIC D SPO SYSTEM
/� INSR CTION
NAME ,c° "� eR 4r VW
LOCA,T I ON
DATE 1 PERMIT ND. " cp
SOIL T - Sand. - Loam - Clay -
Percalat an Test Required? YES - NO
Percolati n rate - Min/Inch
TYPE of SY TEM :
Absorption ield , total len tkiG� {,1'(�?
Length of e h trench
Depth of tre ches r
Size of grave .
SEEPAGE PITS{ er of)
Size- ft. ft . � ..
Gravel size a -
PIPING : Si
.Bldg . to tank i'
Tank to dist. box , f
Dist. box to field/ t rj
Openings sealed? Y S O Partial
LOCATION/SEPARAT (7NS
Foundation to t k ft.
Foundation to sorption '7- lLft .
Absorption to of line �ft .
Separation o pits ft
LOCATION. YSTEM ON PROP TY (circle one)
Front - Rea Left side - ight side -
CCMMENT -
SYSTEM USE APPROVED ES NO
Building Inspector
01/86 and vl
SELEC-r BUSINESS rC3RMS (4509) 84a-5203
APPLICATION FOR ELECTRICAL INSPECTION
PLEASE BEAR DOWN YOU ARE MAKING (4) COPIES
MIDDLE DEPARTMENT INSPECTION AGENCY, INC .
National Headquarters
900 Haddon Ave., Collingswood, N.J. 08108
SECTIONAPPLICANT COMPLETES THIS Date :
City, Town or Township County — r f State
Location/Address
( If Located in Rural Area Please Attach Directions) Pole #
i - ' .z /�
Owner Permit # 45;
Occupied As Building : New old
occupant
Work Area in Building (Floor #, etc. ) :
App, for: Wirin Q Service Q or: Ready for Inspection :
Fee Remitted - $ Cash Q Check M.O. Q Make Payable To : M.D. 1.A.
SOO 75❑ 1000 1250 1500 1350 2000 2250 250tl 2750 3000
Number of Rough Wiring Outlets Elect. Heat _
Switches Amp. Service Surface Unit 'Dishwasher Range
Lighting Water 'Heater Air Conditioner Dryer Pump
Receptacles
Number of Fixtures Oven Garbage Disposal Wiring and Controls for Burner
Amp. Receptacles Fractional H.P. Vent Fans
Other Equipment:
MOTORS If.P. � 1/2 1/12 1/10 1/8 1/5 1/4 1/3 1/2 3/4 1 1 1 : sV� 1 2 1 3 1 5 1 7u2 1 10 1 15 1 20 25 30 1 40 50 1 75 100
Mark Number
of Each Size '
Applicant's
Signature License # Permit .sz
T/A Utility :
ddress: ' ^ ! (NAME) (OFFICE LOCATION
Applicants
(City) (State) Af - (Zip) Service Request #
Phone # 3 Electrician : Dn '
DATE RECEIVED: DATE INSPECTEOr
Correct Location : Same as Above = or :
Red Notice Label Q
Rough Wiring Outlets Surface Unit Oven
Switches Range Garbage Disposal
Receptacles Water Heater Dishwasher
Fixtures Air Conditioner Dryer
Amp. Service Equipment Burner, Wiring & Controls for Amp. Receptacle
Amp. Service Conductors Pump Vent Fans
MOTORS I-1 P 11/2011/12 1/10 1/5 14 7L+z lO 15 2O 25 30 40 5O 75 1100
Mark Number
of Each Size
Elect. Heati—I SOD 1 750 1tl00 1250 1500 1750 2000 2250 2500 275a 700tl
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USE FOR INITIAL VISIT ONLY NOTIFIED DATE FEE FEE PAID
Q RW Progress: Inc. El LKD Q Contractor
0 CFT Violation : Work Comp, Q Inc. CASH 0
0 L/A Owner Fee CHK #
[] L/A Due MO y�
Q IPA Municipal INV #
Appl icant
Date: Other SideQ Utility Owner
I
Cut in Card Q Temp # Date
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