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1992-077 'e CERTIFICATE OF (DIC CUP,A►NC Y TOWN OF QUEENSBURY WARREN COUNTY, NEW YORK tior This is to certify that work requested to be done as shown by Permit No. 92- 077 has been completed. This structure may be c upied as a t i ng i fermi l v dowelling v ri t !, a + +ac tied + .•^- r. ~ r garage Location L*t--ff Arbutus Drive ( Old Forge Park Subdivision ) Larry W . Clute Owner /f 9- _ By Order Town Hoard TOWN OF QUEENSBURY Director of Bldg. & Code Enforcement tZ...y BUILDING PERMIT TOWN OF QUEENSBURY No. 92- 077 WARREN COUNTY, NEW YORK " PERMISSION is hereby granted to LARRY W . CLllTE a OWNER of property located at Lot 62 Arbutus Drive Street, Road or Ave. LID Single Family Dwelling in the Town of Queensbury, To Construct or place a w at the above location in accordance to application together with plot plans and other information hereto filed and ry approved and in compliance with the Town of Queensbury Building and Zoning Ordinance. � t. OWNER'S Address is RR6 , sox 140A Queensbury ICY 12804 r- 2. CONTRACTOR or BUILDER'S Name Self/elute Enterprises Inc . r- 3. CONTRACTOR or BUI LDER'S Address ^S C 4. ARCHITECT'S Name 5. ARCHITECT'S Address mite r-r 6. TYPE of Construction — (Please indicate by X) a N - xX1 wood Frame l I Masonry l } Steel ( ! [ A -s tT c e-t• 7. PLANS and Specifications C to No. 26 ' x42 ' Single family dwelling as per plot plan , specifications and c� application including two- car attached garage and septic system . C CD S. Proposed Use Single family dwelling with two car attached garage Con ca $ 167 _nt.0 _ PERMIT FEE PAID — THIS PERMIT EXPIRES March 19 93 m (If a longer period is required an application for an extension must be made to the Building and Zoning inspector of the _h town of Queensbury before the expiration date.I J: �Y Bated at the Town of Queensbu this D f March 79 92 �o. SIGNED BY for the Town of Queensbury Buy i nd Zoning 1 nopector -- 7 u� TOWN OF QUEEI'NSBURY REVIEWED BY : 00Lt''f TOWN OF OUEENSBURI FEE PAID , .L ; (G `� RECEIVED PERMIT NO . : OV _6 MAR 13 1992 BLDG. & CODE DEPT. BUILDING PERMIT APPLICATION A PERMIT MUST BE OBTAINED BEFORE BEGINNING CONSTRUCTION . NO INSPECTIONS WILL BE MADE UNTIL 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 : L.Cxx-s- •. � P . Q . Address : PHONE `'n7T 7XV2 Property Location : -�, $ r .� � �-- + � -^ Tax Map No . 14 �i Z? tL4 Has there been any split of this property since October 1 , 1988? Yes No >C� If yes , Planning Board Review is necessary . Subdivision Name , if applicable : N-cjrZrAe PCX Lot No . G3Z) THE PERSON RESPONSIBLE FOR Sl/Ur�PERVISION OF WORK AS{y REGARDS TO BUILDING CODES IIS ::y -ry NATURE OF PROPOSED WORK : * ESTIMATED MARKET VALUE OF THE C„ Construction of new building * CONSTRUCTION : $ ��_ C'tt�t'-; . �" Addition to building Alteration to building * COMPLETE INFORMATION REQUIRED BELOW : ( no change to exterior dimensions ) * Size of Property : fto x ft . Other work ( describe ) * Existing Building Size : * -;Z�. ft . x (,0 ; ft . * Proposed building - distance from GROSS AREA OF PROPOSED STRUCTURE : property line : 1st Floor �a Sq . Ft . Id * Front Yard ft . Rear yard ft . r § * Side Yards ft . and �c y� ft . 2nd Floor E2 Sq . Ft . ,. * If on corner , setback from side street- * � Other Floors Sq . Ft .„ ft . (not cellar or basement ) OCCUPANCY INFORMATION , * TOTAL FLOOR AREA :vet ` Sq . Ft . * Primary Building - * One Family Dwelling Size of New Structure : Z2<, ft . x CIZI- ft . * Two Family Dwelling Foundation : * Multiple Dwelling/No . of Units _ Pier/Slab/Crawl /Partial ul Circle One ) * Business * Industrial No . of stories ( Habitable space ) * Other Height ( grade to ridge ) ] ft . If residential , no . of families : t * If addition , what will use be ? No . of rooms ( excluding baths ) : No of bedrooms * No , of bathrooms : �— * Accessory Building : Primary heating system : 4. +r ci r' * Detached Garage - Qne% Type of fuel : * ��- Attached Garage - One wo Car No . of fireplaces t be installed : ► _7lPti * Private Storage Buildin Will a woodstove be installed? : * Other Central Air Conditioning : Yes No ( OVER ) BUILDING PERMIT APPLICATION CONTINUED : BUILDING SPECIFICATIONS : Type of construction : <ii ad from fire safe , etc . Will any second - hand or ungraded lumber be used ? If so , for what ? Foundation Wall Material : r- hickness : Depth of Foundation below grade ( to bottom of footing ) : 77 � Will there be a cellar? l e, S Heated or Unheated ? � , ,� �— — � ,fir � Floor Sq . Footage : Will there be a basement ? - Will any portion be used as living space ? l`.) �Y If so , what portion ? ------ Sq , Ft . Type of Use ? Type of Roof : S1op�eF7at/Shed/other 42 �j&Ae_� Material of Roof c Size , wood studs , spacing (410 " o . c . ; length �6 ft . T Joists ( floor beams ) : 1st Floor Z x lk:3 " ; spacing k o . c . ; span ft , Joists ( floor beams ) : 2nd Floor x spacing a . e . ; span ft . Overlays ( ceiling beams ) : x IN ; spacing o . c . ; span - ft . Roof rafters : "' x - spacing -- - o . c . ; span — ft . Roof trusses ( pre-engineered ) : spacing Z;t V o , c , ; span _ ft . Exterior Wall Finish : ,1 of what material ? °� Inter-i or Wal 1 Finish : Mkk A 6 , AS. _ If a garage is to be attached , de tribe materials to be used for FIRE SEPARATION : ^~ [r Is there to be an opening between garage and dwelling? If so , w ' 11 a e- Rated door , enclosure , self-closing device be provided ? Will a flue- lined chimney be installed ? Height above roof ft , Depth of chimney foundation below grade : (ti,,/ , ft , Depth of fireplace hearth : ft , in . Water supply - Municipal or private well : SEPTIC SYSTEM : Distance from an private well d _ �+ p { including adjoining properties : �ft . (A separate application is necessary for any repair or new installation of septic system . ) TAME OF BUILDER & ADDRESS : C ;S: . �. „�-F- cr s, , ' PHONE �3 NAME OF PLUMBER & ADDRESS : PHONE NAME OF MASON & ADDRESS : ' ' PHONE NAME OF ELECTRICIAN & ADDRESS : PHONE DECLARATION 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 isions of the BUILDING CODE , THE ZONING ORDINANCE , and all other laws pertaini to t e propo work shall be complied with , whether specified or not , and that such work s auth 'Wed the own Signatur Owner , ow er s agent , architect contractor ------------------- SPECIAL CONDITIONS OF THE PERMIT : By : Code Enforcement Officer ENERGY CODE COMPLIANCE APPLICATION TOWN OF QUEENSBURY , WARREN COUNTY - 9000 HEATING DEGREE DAYS C+o■,E„1 i ance Methods: TOWN OF QUEENSBURY RECEIVED PART 5 - Acceptable Practice Method - I & 2 Family Dwellings ( ONLY ) MAR 1 �992 PART 6 - Thermal Rating - Component Trade Offs - 1 & 2 Family Dwellings ; Mu ti - Fami I Owe I i n g s BLDG. & CODE DEPT• ( 3 Stories or Less ) PART 4 - Design By Component Performance - Commercial Buildings - Hi - Rise Residential PART 4 7& 6 - Compliance Methods Require Submission of Worksheets C.L� i APPLICANT05 KAPK PROPERTY LOCATION PART 5 METHOD OF COMPLIANCE BY ACCEPTABLE PRACTICE : 1 . Gross Floor Area - to 9 Z� Sq , Ft . 2 . Type of Heat - Elec . Base Board Otheres � 3 . Is Building Mechanically Cooled ? YES 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 SUBMITI I Baseboard S . Insulation Values : Actual Shown Elec . Heat Other A . Roof 6 Floors exposed to ambient temperatures R �3� B . Exterior Walls R c Cm Glazed Area r..z: rt R D . Exterior Doors R E . Floors over untreated spaces R L� F . Edge of Slab on Grade ( heated Building ) R G . Basement/Cellar Walls (Above Grade ) R //""f, f,,'� H. Basement/Cellar Walls ( Below Grade ) R.!�tc l . Heatin ee -1 rr+g - Ducts. - Piping in Unheated Space R 0 _ 6 . Service ( 'Domestic ) Hot Water Heating Device A . Conforms to minimumefficiency per code ?C YES NO T IURC -CONTROL MAXIMUM SETTING 140• - WILL NOT BE EXCEEDED NT ' B . INSPECTOR ' S REMRKS TOWN OF QUEENSBURY TOWN OF QUEEN SBURfIECEIVED APPLICATION FOR SEPTIC DISPOSAL PERMIT Permit # MAR 13 1992 Fee Paid _ -- Date : Z,I BLD04 & CODE DEFT viewed By LOCATION OF PROPERTY FOR INSTALLATION : G.c�r r Ad C>r oe4 rxz k-� e, Owner ' s Name : �r` Owner ' s Mailing Address . Installer ' s Name : CE- �-�.� ( tom' _ Phone J'ty . -?j ? 'Iry Number of bedrooms ( if residential ) : Total daily flow ( residential - compute @ 150 gal . per bedroom ) : Topography-Circle One : Flat Rolling Steep Slope % of Slope Soil Nature- Circle One :cii 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 : Municip ell Other If domestic water supply is at we Separation : Water supply from any septic absorption feet PROPOSED SYSTEM: Septic Tank ICO C7 gal . ( Minimum size : 1 , 000 gal . ) Tile Field : Each Trench iD feet//Total System Length , feet Seepage Pit ( s ) : Number of / Size each : fto 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 inspectedT�y 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 th o n of Que sbury Sanitary Sewage Disposal Ordinance , SIGNATURE OF RESPONSIBLE PERS DATE : 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 any water supply 5 ) size and dimensions of alanks , distribution boxes , tile fields and/or drywel l s Be 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 . Town of Queensbury Building & Code Enforcement Department 531 Bay Road Queensbury NY 12804 Remarks : TOWN SBURY BUILDING N FCODESNDEPARTMENT 531 BAY ROAD QUEENS8URY , NEW YORK 12804 TELEPHONE (518 ) 745- 4447 BUILDING INSPECTOR ' S REPORT REQUEST FOR INSPECTION RECEIVED NAME LOCATION 7 �r� y — DRi E__ � �PERMI T TYPE OF STRUCTURES RECHECK APPROVED FOOTINGS/PIERS N/A YES NU MONOLITHIC POUR FORM REINFORCEMENT IN PLACE THE CONTRACTOR IS RESPUNSIF3LE FOR PROVIDING PROTES TION FROM FREEZING FOR 48 Hof S FOL WING THE MATERIPLACEMENT FOR TOHP CPOSON ,SITE FOUNDATION/WALL POUR t REINFORCEMENT IN PLACE �, .' j FOUNDATION/DAMPROOFING y_ BACKFILL APPROVAL ROUGH PLING rYPLUMBINGUVENT/VENTS N P CE PLUMBING UNDER SLAB XFRAMING : JACK STUDS/H ADE , BRACING/BRIDGING JOIST HANGERS .LACK POSTS/MAIN BE �-- -- HEATING ROUGH- IN INSULATION : FOUNDATION WA S INTERIOR R- FOUNDATION WA LS E rgRIOR R- FLOORSR- WALLS CEILING R- DUCT WORK GRIPING SPACES IN UNHEATED ARRIVE DEPART INS CT roe 5r OF QUEEXSBURY /� BAY ROAD QUEENSBURY TELEPHONE NEW YORK 32B04 ( 518) 745-4447 [WILDING INSPECTOR 'S RE 4W REQUEST F FIB INSPECTION INSPEcrxoN RECIEXV NAME 'oCArxoN PC�Irf Ty OF STRUCTURE 11111 RECHECK _FIRE MARSHAL APPROVAL CO .FOOTING FOUNDATION hq�1ERICIAt STRUCTURE} ROUGH PLUMBING $ KFILL �FRAMiNG �IIYSULATION �WOMSTOVE/�IREPLACEL --SEPTIC REMARKS , APPROV L CHIMNEY HEIGHT/ CATI N/A YES NO B VENT/LOCATION dw PLUMBING VENT X ROOFING SIDING t DECK/P RCH/5 EPS/ I RELIEF VALVES FURNACE/HOT WA RA NG INTERIOR TRIM/P VAC DOORS FINISH FLOORS : ' ' ITC OTHERKFLOOR SWEEPABL T k OTHER FLOG CARPETED STAIR CLEA CE/RAILING SMOKE DETEC RS DOOR CLOSE BATHROOM F NS ALL PLUMB G FI URES OPE A I GARAGE FI#E PROOFING DOOR CLOSERS OTHER FIRE' S PA N FIRE/DEMISE WALLS -- � FINAL ELECTRICAL �� OK TO ISSUE C/o Al COMM N 5 : ARRIVE DEPART�� I EC R TOWN OF QUEENSBURY BUILDING AND CODES DEPARTMENT 531 BAY ROAD QUEENSBURY , NEW YORK 12804 TELEPHONE (518 ) 745- 4447 BUILDING INSPECTORS REPORT REQUEST FOR INSPECTION 'RECEIVED NAME - LOCATION. � DATE PERMIT e9 7 TYPE OF STRUCTURE .5 RECHECK APPROVED NIA YESI NO FOOTINGS/PIERS MONOLITHIC POUR FORD - REINFORCEMENT IN PLACE THE CONTRACTOR IS RESPONSI LE FOR PROVIDING PROTECTION F ON FREEZING FOR 48 HOURS FOL OWING THE PLACEMENT OF THE CONC ETE . MATERIALS FOR THIS PURPOS ON SITE FOUNDATION/WALL POUR REINFORCEMENT IN PLACE FOUNDATION/DAMPROOFING BACKFILL APPROVAL ROUGH PLUMBING PLUMBING VENT/VENTS IN PLAC PLUMBING UNDER SLAB FRAMING : JACK STUDS/HEADERS BRACING/BRIDGING JOIST HANGERS JACK POSTS/MAIN BEAM HEATING ROUGH- IN INSULATION ' FOUNDATION WALLS INN7 ERIOR R- FOUNDATION WALLS E ERIOR R- FLOORS R- WALLS R- CEILING R- DUCT WORK OR PIP G. UNHEATED SPACES REMARKS : GL-6 &2AA1c,6 WtAa �S""4 "' ARRIVE DEPART INSPEG 0 J?Own n/ Queen jhur yr BUILDING and ZONING DEPARTMENT Bay and Haviland Road, R.D. 1 Box 98 Oueensbury, New York 12801 {J SEPTIC DISPOSAL SYSTEM INSPECTION NAME. � /� J I.00AT ION DATE f PERMIT NO. �a U SOIL TYPE - Sand - Loam - Clay - Percolation est Required? YES Percolation rate -- Min/Inch TYPE of SYSTEM : Absorption field , total length �{ FT- Length of each trench ` Depth of trenches ' l' - u� Size of grave _ .-�+` �. SEEPAGE PITS4Number of) Size- ft. X . ft. Gravel size _ PIPING : Size Type Bldg . to tank cp �� Tank to dist. box yam,. Dist. box to field/pit p,ycr Openings sealed? YES Partial LOCATION/SEPARATIONS Foundation to tank Foundation to absor ion .Absorption to lot 1 ne f t . 14vTP1.*+, (r Separation of pits ft. LOCATION OF SYS ON PROP RT circle one) Front - ea t s - Righ side - CC KMENTS f �71;� �o VA7,M q{�ST7,rtiL r [ r SYSTEM USE APPROVED NO /K •/f�J rr^^--b�o�� Building InApector 01/86 and vl BUILDING AND O QUEENSBURY CODES DEPaRTP4 QUEENSBURYI sAr RQAD TELEPHONE ' NEW PORK 12804 ( 518) 745- 4447 BUILDING INSPECTOR 'S REPORT RE(jIJ .ST FOR c�INNSPECTION RECEIVED NAME_'-- -- �L -- •�— �1 9�--- LOCATIQti DATE — /- 3 PERMIT _ r -Q TYPE OF STRUCTURE RECHECK e. FOOTINGS/PIERS APPROVED MONOLITHICRE POUR FORM _ N/A YES NQ FORCEMENTTHE NCOIVTRACTOR IIS PLACE -- FOR PROVIDING PROTECTIBLE FREEZING F fd OR 48 I HOURS FOLLOWING THE PLACEMENT DF THE CONCRE . MATERIALS FOR THIS PURPOSE TE SITE FOUNDATION/WALL POUR REINFORCEMENT IN PLACE FOUNDATION/DAMPROOFING BACKFILL APPROVAL ,(ROUGH PLUMBING PLUMsING PLUMBING UNDER VENTIVENTS SLAS IN PLACE r..------ FRAMING : JACK STUDS/HEADER + BRACING/BRIDGING JOIST HANGERS JACK POSTS/MAIN g M : HEATING ROUGH— IN INSULATION : FOUNDATION WAL IN ERIQR R— FOUlVDATION WA 5 EXT FLOORS RIOR R— WALLS R_ CEILING R— DUCT WORK R PIPING R_ IN SPACES NHEATED RE R KS : .��^"��yy iZI�,=a C IL FA tO i Lc Jq /VA w 0 ARRIVE " - DEPART I L -� '�� INSPEC OR � C TOW OF QUEENSBURY G ,n BUILDING AND CODES DEPARTMENT531 BAY ROAD 1a1 QUEENSBURY , NEW YO K I2$04 11`� TELEPHONE ( 518) 74 5. 4447 BUILDING INSPECTOR ' S REPORT REQUEST FOR 'NSPECTIOH RECEIVED LOCATI DATE-- PERNIT # TYPE OF STRUCTURE RECHECKT �'� -- APPROVED OT� S/PI N/A YES MONOLITHIC POUR ORM _ REINFORCEMENT III PLACE "�' -- THE CONTRACTORFOR IS RESPOMSI 0�Ef FREEZIG IFOR 48 PROTECT }QURSION FR Q LQMII�f6 THE PLACEMEIi T OF TOE CONCRFfiE. MATERIALS FOR THIS PURPOSE,+"ON SITE FOUNDATION/WALL POUR REINFORCEMENT IN PL GE FOUNDATION/DAMPROOFIWG BACKFILL APPROVAL ROUGH PLUMBING Y PLUMBING VENT/VEN S I PLA E PLUMBING UNDER SLAB FRAMING ; JACK S UD MEADS BRACING/BRIDGING -- JOIST HANGERS — JACK POSTS/A74IN BEAM HEATING ROUGH- IN INSULATION: FOUNDATION WAL N E OR FOUNDATION WALLS EXTERIOR R- FLOORS WALLS R- CEILING R` DUCT WORK OR PI ING IN UNHEATED SPACES REMARK cL . ARRIVE DEPART WtPECTO`R� i 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 RECEIYEO �/ ra NAME od� LOCATION DATE . PERMITJer # TYPE OF STRUCTURE ` RECHECK APPROVED FOOTINGS/PIERS N A YES NO MONOLITHIC POUR ORM REINFORCEMENT IN PLACE THE CONTRACTOR IS RESPONSIBLE FOR PROVIDING PROTECTION FROM' FREEZING FOR 48 HOURS FOLLOW NG THE PLACEMENT OF THE CONCRET . MATERIALS FOR THIS PURPOSE O SITE FOUNDATION/WALL POUR REINFORCEMENT IN PLACE v FOUNDATION/DAMPROOFING SACKFILL APPROVAL ROUGH PLUMBING + " PLUMBING VENT/VEN S IN PLACE PLUMBING UNDER SLAB FRAMING . JACK STU S/HEADERS BRACING/BRIDGING JOIST HANGERS ��-- JACK POSTS/MAIL BEAT"y HEATING ROUGH- IN INSULATION : FOUNDATION W L N ER FOUNDATION WALLS EXTER R R- FLOORS R_ +. WALLS R- CEILING R- DUCT WORK OR PIPING N UNHEA E SPACES H ARRIVE DEPART IN EC OR 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 LOCATIONS DATE PERMIT TYPE OF STRUCTURE RECHECK AP ROVED N/A YESI NO J'�1[ FOOTINGS/PIERS MONOLITHIC POUR FOR REINFORCEMENT IN PLACE THE CONTRACTOR IS RESPOLNSFIBR FOR PROVIOIN6 PROTECTIO FREEZING FOR 48 HOURS FTHE PLACEMENT OF THE COMATERIALS FOR HIS PURP FOUNDATION/WAL POUR REINFORCEMENT I PLACE FOUNDATION/DAMPRO ING BACKFILL APPROVAL ROUGH PLUMBING PLUMBING VENT/VEN S MPLACE PLUMBING UNDER SLAB It FRAMING • JACK STUDS M EADERS BRACING/BRIDGING JOIST HANGERS JACK POSTS/MAIN EAM HEATING ROUGH- IN INSULATION • FOUNDATION WAL S INTERIOR R- FOUNDATION WA S EXTERIOR R- FLOORS R- WALLS R- CEILING R- I WORK OR PIPING IN UNHEATED' SPACES REMARKS : E,,,ett e rzt� t610 j r,T-1 A r- 4- N-v— rr cCVT,,," r cam+ j Ent ARRIVE 1 0 —r� t DEPART 0 r y 5 �- IN PEC R National' Headquarters w 1337 Weser IChestei-�IO ;West�'�i83tr�;�Pi4 19380 Date : City, Town or Township County ; F state k Lcrcati pn/Add reSS y dc (If Lated in Rural Area - Please Attach i tuns 'Pole # Owner .�.,�.. ' Perm t Occupied As _ '-Suildilip: - N iw* Old O Occupant #...r 'Work Area in Buildin Floor #, etc.1: App. for: Wiring 0 Service ED or: Ready for lnspeotibi'* Fee Remitted - $ cash Check ED ' ` = It1:C} - Maker Payable 'ro: M.D. I.A. Number of R"h Wiring Outlets Elect. Heat _ Soo I i5o 1:0 1250 ls*0 1 2000 2250 2500 2750 3000 Switches- Lighting — �- r Amp. Ser%doe Stillace Uril;t Dishwasher Range Receptacles c1f Water Heater Air Conditioner �.rDryer .-,.Pump Numbef Fix ure Oven Garbage Disposal Wiring and Controls for Burner • A ap.4 Receptacles: - Fractional H.P. Vent Fans Other Equipment: MOTORS H.P, /2 1/1 1/14 1/9 1/6 1/4 1/3 1/2 3/4 1 lift 2 3 5 7ah 10 15 20 7-5 34 40, 5p 75 - 140 Rftrk Number of Each Size , Applicant's Signature License # ` Pexmit # . T/A d7 wtility: NAME -- -. - T FUN) Applicant's Address: Q I' {�,_.__.['` !w 16fg Ai (city) � �� � ' 1_1, (Zip) "!'M g;j`j Service Request # ` y 5�w., r (Sxatel Phone # Ele Cician : '6' -rE RECEIVED: pATE INSPE&TED 7.7 me as AboveEj or: ng Outlets Surface Unit Oven Ran _ oal b Oi3 seff Water Heater "~ C7ishvAragher •' Fixtures AfrCon tibneY Dryer Amp. Service Equipment Burner, r'i rYYrols for Amp' Atootacle Amp. Service Conductors Pum Vent Fans MOTORS H.P. 1/20 1/12 1/16 1/6 1/6 1/4 1/3 1/2 3/4 ' • l�fx • 2 -3" w `• 7V2 10 15 20 25 46 'S6 75 Mark Number ;.I a of Each Size - - c. w Elect. Heat 50n 750 1000 1250 ISDO 1T'.�q 006 2230 2305 �2750 $OpO ,•; , Q` R W Progress: Inc. 0 L IC D {l' Contractor Q CFT Violation : Work. Comp. Inc. - , .- �] L/A ~Owner CASH E CD L/A Fee CHK # MO 0 IPA ; fVlur2jcipal . [flue - - �:. . INV # Date: Other Side Utility Applicant Owner Cut in Card Temp # - Dale. - Q Final # Date - llV9l�EGY #iS IGMATURE! APPL1CAT1 OWN FORM N0. 250L L: '11/aa3 ' - • - . .., , . < ��►} So I ��, ��, r,es i } FF1 v i 1 f bWN OF OUEENSBUR-i RECEIVED 3 1992 BLDG. & CODE DEPT,