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1992-027 CATIE OF TOWN OF QUEENSBUky } WARREN COUNTY, NEW YORK Date 92 5 It _ f I 92-1027 'This is to certify that work ,requested to be done as shown by perttuit N o. _ has been completed. �I TUis structure may be occupied a• a Single Fatai l7': SDwe11 ing IM ation Lot L.ehland Jac ueline Drive r Guido Passarelli By Order Town Board TOVYN OF QUEENSBURY r Director of Bldg. & Code Enforcement BUILDING PERMIT se TOWN OF +QUEENSBUR.Y LC No. 92-027 x WARREN COUNTYe NEW YORK PERMISSION is hereby granted to Lehl and Estates 1 OWNER of property located at __ Lot #20 Lehl anti Estate street, Road or Ave. in the Town of Queensbury. To Construct or place s Single Family nwallingl 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. r t. OWNER'S Address is Sox 45 w Herald Drive a. ueensbur NY 1 80 rM 2. CONTRACTOR or BUILDER'S blame W Pt Passarelli /Cerrone en 3. CONTRACTOR or BUILDER'S Address O ear *Ms O 4. ARCHITECT'S Name ifY J J 5. ARCHITECTS Address 6. TYPE of Construction — (Please indicate by X1 (X) wood game I 1 Masonry J. 7 W 7_ PLAINS and Specifications No. 2002 sq ft Single Fancily Duelling as per plot plan specifications and application S. Proposed use Single Family Duelling $ _28PERMIT FEE PAID — THIS PERMIT EXPIRES January 29 i9 93 (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.) Dated at the Town of Queensbury this 29th Day of _ January 1992 for the Town of (Queensbury SIGNED BY Building and Zoning inspector TOWN or QUEENS81URY 46 c�'^ REVIEWED BY : fir] FEE PAID . PERMIT NO * j � �Q� �+ sT©WP4 OF QUEE►1 4:0"4L;"y BUILDING PERMIT APPLICATION „fA A PERMIT MUST BE OBTAINED BEFORE BEGINNING CONSTRUCTION . NO INSPECTI %6jLV ',k4Q8j& 4!66& W4 APPLICANT HAS RECEIVED A VALID BUILDING PERMIT . All applicants spaces on this application MUST be completed and the signature of the applicant MUST appear on the reverse side of this application . * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * Owner of Property P . O . Address : ?fir} k 1I. " r�E �� r� z e 01. b /Y L.I PHONE Zjy Property Location : �- sTw rc� � Tax Map No . 7Yr/ ?_ / 2.c') Has there been any split of this property since October 1 , 1988 ? Yes No If yes , Planning Board Review is necessary . Subdivision Name , if applicable : 4 etL J J J, T. rem-, , _ Lot No . �27,t THE PERSON RESPONSIBLE FOR SUPERVISION OF WORK AS REGARDS TO BUILDING CODES IS : NATURE OF PROPOSED WORK : * ESTIMATED MARKET VALUE OF THE /" Construction of new building * CONSTRUCTION : $ Addition to building Alteration to building * COMPLETE INFORMATION REQUIRED BELOW : ( no change to exterior dimensions ) * Size of Property : ft . x ft . Other work ( describe ) * Existing Building Size : * ft . x ft . * 'used building - distance from GROSS AREA OF PROPOSED STRUCTURE : * property line : * 1st Floor ,add / Sq . Ft . 49 * Front Yard _sue ft . Rear yard �J e> ft . / U Q * Side Yards '/ ft . and _/J `,r ft . 2nd Floor / v 0 / Sq . Ft . � �- �_ * If on corner , setback from side street- Other Floors Sq . FtZ S * ft . (not cellar or basement * OCCUPANCY INFORMATION : * TOTAL FLOOR AREA : ,�2�22 a Sq . Ft . * Primary Building * v One Family Dwelling Size of New Structure : d/,5> ft . x ft . * Two Family Dwelling Foundation : * Multiple Dwelling/No . of Units Pier/Slab/Crawl /Partial /Full ( Circle One ) * Business * Industrial No . of stories ( Habitable space ) o * Other Height ( grade to ridge) ft . If residential , no . of families : �, ,, * If addition , what will use be? No . of rooms ( excluding baths ) : _ No. of bedrooms : �,3 No . of bathrooms : A ':/ ;Z * Accessory Building : Primary heating system: c� ,Ay 7r - * Detached Garage - One/Two r Type of fuel : * Attached Garage - One/ wo No . of fireplaces to be insta ed : �; * Private Storage Build ng Will a woodstove be installed? : p * Other Central Air Conditioning : Yes No ( OVER ) BUILDING PERMIT APPLICATION CONTINUED : BUILDING SPECIFICATIONS : Type of construction : wood frame , fire safe , etc . a Will any second- hand or ungraded lumber be used ? If so , for what ? Foundation - Wai l Mi. er.'i a i- c c' ' � , T Thickness : " Depth &F Foundation, .belowls4�ade ( to bottom of footing ) : Will the� e b6 a cellar ? Heated or Unheated ? F Will there_ .:. laar Sq , Footage : bey a. basei"t? ' ---4) is Will any portion be used as living space ? ,yam If so , what portion ? - Sq . Ft . Type of Use ? Type of Roof : Sloped/Flat/Shed/Other ; �, v_ Material a l of Roof Size , wood studs — — ''-.�Rb — _�� x spacing / 4/, -s' o . c . ; length ft . Joists ( floor beams ) : 1st Floor it x 'Joists ( floor beams ) : 2nd Floor ` spacing ,rr �' Q . c . ; span _ I4 ft . x " ;Overlays ( ceiling beams ) spacing _-_f_t�_ o . c . ; span _ I.� ft . : " x " ; spacing o c . ; span ft . Roof rafters : " x " ; spacing o . c . ; span ft . Roof trusses ( pre-engineered ) : spacing c L O . C . ; Span ft . Exterior Wall Finish : Of what material ? Interior Wall Finish : , If a garage is to be attached , describe materials to be used for FIRE SEPARATION : Is there to be an opening between garage and dwelling ? 4 _ enclosure , self- closin device be 7 g ' If so , will a Fire-Rated door , 9 provided . Will a flue- lined chimney be installed? Height above roof ft . Depth of chimney foundation below grade : ft . Depth of fireplace hearth : ft . PIIIIIIIIIIIIIII in . Water Supply - Municipal or private well : t SEPTIC SYSTEM : Distance from any private well ( includingadjoining 9 properties . ft . (A separate application is necessary for any repair or new installation of septic system. ) NAME OF BUILDER 3 ADDRESS : {� NAME OF PLUMBER & ADDRESS : PHONE Yy, :L" Z Ga_ i NAME OF MASON & ADDRESS : _ PHONro z' PHONEr y ti ! _ NAME OF ELECTRICIAN & ADDRESS : �- 2�' c �PHONE-22d— DECLARATI Off To the best of rRy 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 worts is authorized by the owner , Signatur a ner , owner s agent , architect contractor By: Code n orcement cer ENERGY CODE COMPLIANCE APPLICATION TOM OF QUEENSBURY , WARREN COUNTY - 9000 HEATING DEGREE DAYS Compliance Metlwds PART 5 - Acceptable Practice Method - I & 2 Family Dwellings ( ONLY ) PART 6 - Thermal Rating - Component Trade Offs - F & 2 Family Dwellings ; Multi - Family Dwellings ( 3 Stories or Less ) PART 4 - Design By Component Performance - Commercial Buildings - Hi - Rise Residential PART 4 & 6 - Compliance Methods Require Submission of Worksheets PR�(7 P `I E�Y L�i �I Nll���� A�LICCAN�NAME PART 5 METHOD OF CONPLIAMCE BY ACCEPTABLE PRACTICE : 1 . Gross Floor Area - a n<> ,9L�- Sq . Ft . 2 . Type of Heat - Elec . Base Board Other yc�:� s 3 . Is Building Mechanically Cooled ? YES tf NO 4 . Percentage of Area of Windows and Doors Over 17% / -Under 17% THE R-VALUES GIVEN ON THIS SHEET MUST CORRESPOND TO R E Q U I R E D THE R-VALUES SHOW! ON PLANS SUBMIT Baseboard 5 . Insulation Values : Actual Shown Elec . Heat Other A . Roof & Floors exposed to ambient temperatures R � B . Exterior Walls R. IT C . Glazed Area R D . Exterior Doors R E . Floors over unheated spaces R F . Edge of Slab on Grade ( Heater! Building ) R G . Basement/Cellar 'Walls (Above Grade ) R f3 H. Basement/Cellar Walls ( Below Grade ) R t.3 I . Heating/Cooling - Ducts - 'Piping in Unheated Space A 6 . Service (Domestic ) Hot water Heating Device_ A . Conforms to minimum efficiency per code ✓ YES NO TEP64 MTURE CONTROL NUINUM SETTING 140• - WILL WT BE EXCEEDED TELEPHONENUMBER INSPECTOR ` S REMARKS : ,a-A5ff TOWN OF QUEENSSURY APPLICATION FOR SEPTIC DISPOSAL PERMIT Permit # Fee Paid Date : I / /gam Reviewed By LOCATION OF PROPERTY FOR INSTALLATION : Owner ' s Name : C_ `4 Zn P;� z r,- e_ 41G t Owner ' s Mailing Address : .Y,5' ! 4 Installer ' s Name : C { ` 4 C' ,Z " Phone # : Number of bedrooms ( if residential ) : 3 Total daily flow ( residential - compute @ 150 gal . per bedroom ) : Topography- Circle One : Klat Rolling Steep Slope % of Slope Soil Nature- Circle One : Sand Loam Clay Other /Depth : Ground Water-At What Depth ? Feet Bedrock or Impervious Material -At What Depth? Feet Percolation Test- Circle One : Not Required Required/ Rate Min . Per 'inch Domestic Water Supply-Circle One Municipalell Other If domestic water supply is weZ -�T Separation : Water supply from any septic absorption lyd'�2 j4:5 feet PROPOSED SYSTEM: Septic Tank 11+, ,26r-o gal . ( Minimum size : 1 , 000 gal . ) Tile Field : Each Trench ,05-,c> feet//Total System Length e2 feet Seepage Pit ( s ) : Number of / Size each * ft . x ft . Size of Stone to be used : # / Depth or Thickness feet HOLDING TANK SYSTEM IF REQUIRED No . of Tanks Sizelof Each Gal . Alarm system and associated electrical work to be inspected by a certified agency. 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 Queensbury Sanitary Sewage Disposal Ordinance . SIGNATURE OF RESPONSIBLE PERSON : u 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 2 ) location and distance to lot lines 3 ) location and distance to structures 4 ) location and distance to a_M 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 $ 250000 . 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 , Town of Queensbury Building & Code Enforcement Department 531 Bay Road Queensbury NY 12804 Remarks : Bay at HavllarW ft"di inab'wY. KY0 12$014725 APPLICATION FOR SOLI?-FU$ . BURNING APPLIANCES AND FIREPLACES _ '� +^j Date .r /a g` 19 ?Ax Permit 1�Io. ` A1'l'l-al (:A'I'I()N IS HERESY MA rE to the }uitding Department for the issuance of a Building and Use Permitpursuant to the New York State Fire Prevention GAO RUMing Code. The applicant or owner agrees to comply with all � applicable laws, ordinances, regulations and all conditions that are part of these requirements and also will n4ow all inspector; to enter premises for the required inspections. p APPLIANCE TYPE Applicant 's Name pi d ,�.�+ ssa Y �, w Coal Wood A�dtlress r - Furnace Hot Air Boiler Zero Clearance _Circulating Unit fig zip jel rild Phone If NowteMasonry: jnv ✓4P C„�.0mr * -0 w c. -....---- - Owner's Name Manufacturer Address +� � Model --- Outlet Size / `• zip Listed by Number 1'Ito lll' CHIMNEY TYPE Masonry: Block Brick Stolle Property localion of proposed construction Flue: Tile Steel Size: Factory Built: Manufacturer Model Size COPY OF MANUFACTURER SPECIFICATIONS IS Heigrit Listed Qy Number,- i ENQUIRED FOR FACTORY-BUILT APPLIANCES Type: bauble Wall Triple Wall ,. AND CHIMNEY& MUST BE INSTAIwLEI) Insulated F ACCORDING TO SPECIFICATIONS. C,Q,]9V:. Estimated Cost $ CONSTRUCTION DETAIL REQUIRED Fee S S(INRY FIREPLACES AND CHIMNEYS. TOWN OF (JUESNSOURY, NEW YORK lDerxarlmenl• Fire Marshal Amoum Collected Amount Refunded Cade Number • � _ k . ' it ":7- A 173 3389 (190) Public Safety r, A23-3 1.655 (230) Mirror Sales r Fcc Collected from or Refunded to: Addr ms: 11 Dated: Town Clerk or Depaty WA1Afr: aE.. yo 'r11 1 1� r a F.ne Aal�►sA`or: TOWN OF QUEENSBURY yy FIRE MARSHAL QUEENSBURY , NEW YORK 12804 ,•_'/ TELEPHONE ( 518 ) 745- 4424 FIRE MARSHAL INSPECTION REPORT REQUEST FOR INSPECTION RECEIVED ////� awt NAME LOCATION ( _- DATE , ���Q2. PERMIT# !Z2 -,5)9 ' 7 V APPROVED N/A YES NO EXITS AISLE WIDTHS EXIT SIGNS EMERGENCY LIGHTING FIRE EXTINGUISHERS JO AUTO . EXTINGUISHIN SYSTEM HOOD INSTALLATION 1 AUTO . SPRINKLER SY TEM_ ALARM SYSTEM INTERIOR FINISHES STORAGE : CLEARANCE P NKLERS CLEARANCES `CO HE TING UNITS REQUIRED SIrGNAGE CHIMNEY ODSTOVE FIREPLACE-MAS NR FIREPLACE-FACTORY BUILT do REMARKS ; Lj OK TO THIS DI TE 2/015 IN PECTOR TOM OF QuEENSBURY 531 BAY ROAD QUEENSBURY , NEW YORK 12804 TELEPHONE ( 518 ) 745- 4447 BUILDING INSPECTOR' S REPORT FINAL INSPECT! j REQUEST FOR INSPECTION RE IVED� /// NAME �C22 LOCATION DATE yam,// ' PERMITf TYPE OF STRUCTURE RECHECK FIRE MASHAL APPROVAL ( COMMERCIAL STRUCTURE ) FOOTING FOUNDATION BACKFILL }AFRAMING 'vROUGH PLUMBING kFINAI?CELECTRICAL xCSEPTIC;k�- INSULATION �WOODSTOVE/FIREPLACE REMARKS/kAjA woe. ~ APPROVAL N /Al YES NO CHIMNEY HEIGHT/LOC ION v" B VENT/LOCATION W PLUMBING VENT ROOFING SIDING DECK/ PORCH/STEPS/RA NGS _ RELIEF VALVES _ FURNACE/HOT WATER RA IN BASEMENT INSULATI / UCTWORK INTERIOR TRIM/ PR AC DOORS FINISH FLOORS : BATH/ KITCHEN ATERT HT OTHER FLOORS WEEPAB E OTHER FLOORS! CARPETE STAIR CLEARANCE/ RAILING HANDICAPPED ACCESS SMOKE DETECTORS BATHROOM FANS/ ALL PLUMBING FIkTURES OPER TING GARAGE FIRE PROOFING �. DOOR CLOSERS t/ OTHER FIRE S £PARA i N FIRE/DEMISE WALLS DUMPSTER SITE PLAN/ VARIANCE PLAN/ VARIANCE REQUIREMENTS FINAL ELECTRICAL OK TO ISSUE C /O OR C/C COMMENTS : / ARRIVE DEPART INS �eawr� o� �ueeeres�eerr� BUILDING and ZONING DEPARTMENT Bay and Haviland Road, R.D. 1 Box 98 Queensbury, New York 12801 SEPTIC DISPOSAL SYSTEM INSPECTION NAME LOCATION DATE „ / i PERMIT NO. SOIL TYPE Sa - Loam - clay - Percolatian et Required? YES - Percolation rate - Min/Inch /a, TYPE of SYSTEM: Id Absorption f ield , total leng .h Length of ach trench r Depth of t nchesLA Size of gra 1 _ SEEPAGE PITS umber of) --- Size- ft. ft Gravel size PIPING : Size Type Bldg . to tank S�F r�' G. Tank to list. box Y~ oozed Dist . box to fie / _ , yfT Openings sealed NO Partial LOCATION/SEPA TIONS : Foundation t tank ft. Foundation absorption v ft . Absorption o lot line C..) ft. Separatio of pits ft. LOCATION SYSTEM ON PROPER (circle one ) Front - ear - Left side - Right side - CCf4MENT Loa, r $' I �'4 �CI SYSTEM USE APPROVED 60NO Building inspector 01/86 and vl TOWN OF QUEENSBURY BUILDING AND CODES DEPARTMENT 531 BAY ROAD QUEENSBURY , NEW YORK 12804 TELEPHONE ( 518 ) 792- 5832 BUILDING INSPECTOR' S REPORT REQUEST FOR INSPECTION RECEIVED LOCATION DATE PERMIT # TYPE OF STRUCTURE ' RECHECK APPROVED N/Al YES NO FOOTINGS/PIERS MONOLITHIC POUR Fh _._.... REINFORCEMENT IN PLACE THE CONTRACTOR IS RESPON I�BLE FOR PROVIDING PROTECTION FROM FREEZING FOR 48 HOURS LOWING THE PLACEMENT OF THE ONCRETE. MATERIALS FOR THIS P POSE ON SITE �. FOUNDATION/WALL POUR REINFORCEMENT IN PLAC FOUNDATION/DAMPROOFIN BACKFILL APPROVAL ROUGH PLUMBING N PLUMBING VENT/V N a IN E PLUMBING UNDER SLAB FRAMING : JACK STUDS/HEADERS BRACING/BRIDGING r =, JOIST HANGERS JACK POSTS /MAIN BEAM/ FIRESTOPPING WALLS CEILING FIREWALLS HEATING ROUGH- IN INSULATION : FOUNDATION WALLS IN E - FOUNDATION WALL EXTERIOR R- FLOORS R- WALLS CEILING R- DUCT WORK 0 P P I G N N EA ED S PAC ES REMARK ARRIVE DEPART �' =.�-, SP C TOM OF QUEENSBURY FIRE MARSHAL QUEENSBURY , NEW YORK 12804 TELEPHONE ( 518 ) 792- 5832 FIRE MARSHAL INSPECTION REPORT REQUEST FOR INSPECTION RECEIVED Vol9;2 NAME_ � .�n P � LOCATION DATE ^* ERMIT# C 472 - t' 1 APPROVED E% ITS N!A YES NO AISLE WIDTHS- EXIT SIGNS EMERGENCY LIGHTING FIRE EXTINGUISHERS AUTO . EXTINGUISHING YSTEM HOOD INSTALLATION AUTO . SPRINKLER SYST ALARM SYSTEM INTERIOR FINISHES STORAGE . CLEARANCE TO SPRI KLER CLEARANCE TO HER ING UN S REQUIRED SIGNAGE CHIMNEY WOODSTOVE - MASON-MAS RY FIREPLACE- FAG ORY BUILT REMARKS : 0 K TO IVIIS DATE ARRIVE DEPART I SP CTO TOWN OF QUEENSBURY BUILDING AND CODES DEPARTMENT 531 BAY ROAD QUEENSBURY , NEW YORK 12804 TELEPHONE ( 518 ) 745-4447 BUILDING INSPECTOR' S REPORT _ REQUEST FOR INSPECTION RECEIVED NAME LOCATION DATE PERMIT # cap TYPE OF STRUCTURE RECHECK APPROVED N/A YES NO FOOTINGS/PIERS MONOLITHIC POUR F RM REINFORCEMENT IN PLACE THE CONTRACTOR IS RESPONSIBLE FOR PROVIDING PROTECTION FROM FREEZING FOR 48 HOURS FOLLOWING THE PLACEMENT OF THE CONCRETE. MATERIALS FOR THIS PURPOSE ON SITE FOUNDATION/WALL POUR F REINFORCEMENT IN PLACE FOUNDATION/DAMPROOFING BACKFILL APPROVAL ROUGH PLUMBING PLUMBING VENT/V IN PLACE PLUMBING UNDER SLAB ' RAM INGa JACKS DS/HE DERS, _............... BRACING/BRIDGING JOIST HANGERS _ JACK POSTS/MAIN BEAM HEATING ROUGH- IN INSULATION : FOUNDATION WALLS IN TE OR FOUNDATION WALLS EXTE OR R- FLOORS R- WALLS R- CEILING R- DUCT WORK OR PIPIN IN UNHEATED SPACES REMARKS : ARRIVE DEPART INSPE OR TOWN OF QUEENSBURY BUILDING AND CODES DEPARTMENT 531 BAY ROAD QUEENSBURY , NEW YORK 12804 TELEPHONE ( 518 ) 792- 5832 BUILDING INSPECTOR' S REPORT REQUEST FOR INSPECTI,,ON-- RECEIYED. �y j--`"'� wmE IL61PAOD �S LOCATION _ fl DATE io Z ' PERMIT # Qr/ t7 ,tii TYPE OF STRUCTURE RECHECK APPROVE N/A I YE54 NO FOOT NGS/PIERS MONOLITHIC POUR O REINFORCEMENT IN PLACE _ THE CONTRACTOR IS RESPONN IBL� FOR PROVIDING PROTECTION FROM FREEZING FOR 48 HOURS FOLLOWING THE PLACEMENT OF THE CONC ETE . MATERIALS FOR THIS PURPO ON SITE FOUNDATION/WALL OUR REINFORCEMENT I PLACE FOUNDATION/DAMP OOFING BACKFILL APPROV L ROUGH PLUMBING PLUMBING VENT/ VE S LACE PLUMBING UNDER S B FRAMING : JACK STUDS /HEAD S BRACING/BRIDGIN JOIST HANGERS JACK POSTS / B AM FIRESTOPPING WALLS CEILING FIREWALLS HEATING ROUGH- IN INSULATION : FOUNDATION MALLS IN E IOR R- FOUNDATION WALLS EXTERIOR R- FLOORS R' WALLS R- CEILING R- DUCT WORK OR PI ING IN UNHEA ED SPACE REMARKS : ARRIVE DEPART INSPEC R TOWN OF QUEENSBURY BUILDING AND CODES DEPARTMENT 531 BAY ROAD QUEENSBURY , NEW YORK 12804 TELEPHONE ( 518 ) 745- 4447 BUILDING INSPECTOR' S REPORT REQUEST FOR INSPECTION} RECEIVED J NAME LOCATI4N0 ,2,enr�j , 9 -0 UATE� PERMIT if G � 12z2 7 TYPE OFF —STRUCTURE RECHECK APPROVED N/A YEcil NO S/PI RS _ ONOLITHIC POUR FORM F _ REINFORCEMENT IN PLACE THE CONTRACTOR IS RESPONSIB E FOR PROVIDING PROTECTION FR FREEZING FOR 48 HOURS FOLLO NG THE PLACEMEW OF THE CONCRET MATERIALS FOR THIS PURPOSE 0 TE FOUNDATION/WALL POUR REINFORCEMENT IN PLAC FOUNDATION/DAMPROOFING BACKFILL APPROVAL ROUGH PLUMBING PLUMBING VENTJVENTS IN PLA PLUMBING UNDER SLAB FRAMING : JACK STUDSMEADERS BRACING/BRIDGING JOIST HANGERS JACK POSTS/MAID HEATING ROUGH- IN INSULATION : FOUNDATION W LLS TERMIR R- FOUNDATION WALLS XTERIOR R- FLOORS RR~ R- CEILING R- DUCT WORK OR PIFING IN UNHEATED SPACES REMARKS : ARRIVE 9 DEPART ? t� ~S INSPECT9A �►' , " ! � �►� �!� �r:;oars��,r�x���r � —..... National Headquarters } /+ 1337 We4-_ est6f*lQe, *4t CheS40*'IPA`-419380 Date . City, Town or Township <yr��s e ,r �atr� County I of- Lb we it om 0 q State 494 x ;- Lo �40cation/Address s # ed ( ocat In Rura Area - Please Attach Directions) Pole # Owners " .1­1 4 Occupied As building: NeW� Older Occupant W6r'k Area in Building Floor #, etc. ) ; App. for: Wiring E3 Service EJ or: Ready for Inspecticnl : Fee Remitted- $ Cash 0 Check CA M. .= " MAkd Pa able To: M.D. 1.A. Number of Rough Wiring'Qutlets Eked. Heat 384 .54 1444 Y254 1544 1754 2004 2254 2544 2760 3040 Switches Amp. S�enrieW Suurface Unit Dishwaaheir Range Lighting Water Heater Air Conditioner Dryer Pump Receptacles.Numttier of Fixtures Oven Garbage Disposal Wiring and Controls for Burner -"� Moll.' Rec$ptaclear. Fractional H-P. Vent Fans ~= Other Equipment: MOTORS H.P. /2, ]�/ 1,/14 1/8 1/7 1/4 1/3 1/2 8/4 1 11/2 2 - 3 5_ 7=!z 10 15120 25 3014.0 50 75 100 Mark Numlter -'- I _ I . _�^ of Each Size t. Applicant's Signature L"lcense # Pero lIt # T/A pyti lity : Applicant's Address: (NAM IC L CA I (City) (State)— _ _- -- (Zip) Service Request # Phone # ' Elaciriciao:, AAVZ RECEIVED: DATE INSPECt`Ebt - . Correct Location : Same as Above 0 or:. Red Notice Label 1P . Rough Wiring Outlets Surface Unit Oven Switches Range tAlrbage ippklszii '% Receptacles Water Heater sshvf�fsixxr Fixtures >sciFonc�itiane+r '" ` + 3ry er - _ Amp, Service Equipment Burner, Wiring'& Cor►t1-ols for Amp. Receptacle Amp. Service Conductors Pump Vent Fans MOTORS F1.P. I/20 1/12 1/10 1/8 1M/213/4 .1'Y . Ys= . 2'.: �: :J � f S'.. 7=Ix �10 15 20 2s 3fl 40 B• '75 •1 'Mark NumberIt of Each Size • ' " Elect. Heat 540 7511 10011 1250 1500 1754 2000 2254 .15£i0 2754 3000 M " T. - : 0 RW Progress: Inc. F1 LKOM Contractor CFT Violation : Work Comp. Inc. [] © L/A Owner CASH Fee a IJA CHK MO ## Due � IPA _-. 3 . . _ _ Municipal - INV #k ApplicantApplican , .8 Date: - Other. Side Utility Dwrler Cut in Card 0 Temp # Dateoz.l Q ,Final # Date �Fi INSPIWTI SSIGNATURE APPLICATION FORM NO. 254 L 11/88 ' - - i CAS LVZ. MI �� o L S / / f ' / L �rp� I1 /fCi a )GI AA fol if in i IrP of R` �y� � IU is Li let h