88-309 CERTIFICATE OF OCCUPANCY
TOWN OF QUEENSBURY
WARREN COUNTY, NEW YORK
Date June 26 19 89
This is to certify that work requested to be done as shown by Permit No. 88-309
has been completed.
This structure may be occupied as a Addition to One Family Dwelling
Tee Hill Rd.
Location
Owner Bruce Williams
By Order Town Board
TOWN OF QUEENSBURY
Building & Zoning Inspector
BUILDING PERMIT
yHy
DC
TOWN OF QUEENSBURY
No. 88-309
WARREN COUNTY, NEW YORK
PERMISSION is hereby granted to Bruce Williams
Tee Hill Rd. O0
OWNER of property located at Street,Road or Ave.
in the Town of Queensbury,To Construct or place a Addition to One Family 1`..)
•
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 RRl Box 217
Glen Lake
Queensbury, N.Y. 12801
0
CD
2. CONTRACTOR or BUILDER'S Name
r•
Same
N•
Iv
E
3. CONTRACTOR or BUILDER'S Address
Same
4. ARCHITECT'S Name
m
CD
I-.
5. ARCHITECT'S Address �y
6. TYPE of Construction—(Please indicate by X)
(X)Wood Frame ( ) Masonry ( 1 Steel ( 1
0>
7. PLANS and Specifications -ts.
F,.
No. 20' x 30' addition as per plot plan, specifications and application
1-6
including septic system.
8. Proposed Use 'rt
Addition to one Family °
0
1-4
m
$5.00 C/O
42.00 December 1, 88
$ PERMIT FEE PAID—THIS PERMIT EXPIRES 19
(If a longer period is required an application for an extension must be made to the Building and Zoning inspector of the ty
town of Queensbury before the expiration date.) $
(D
Dated at the Town of Queensbury this 31st Day of May 19 88
SIGNED BY for the Town of Queensbury
Building an oningInspector
INTERIM BUILDING PERMIT
PERMIT APPLICANT
.----- ,fice :,:_et4,3z,z,
CONSTRUCTION LOCATION iej� /, : 4<./( .iee
EFFECTIVE DATE ... - !r
APPROVED BY
SPECIAL CONDITIONS :
--5'' /ki -/-..4,4_ 4 d-tr-e,-ee.e to I
Ao C4eWA:41_,
This will certify that all submittals for a Building
Permit have been received and fee has been paid .
During the processing of the Permit, the above named
may begin construction per plans submitted. It is the
responsibility of the applicant to obtain the Permit •
from the Building Department, following processing .
POST THIS INTERIM PERMIT IN A CO SP OU CA ON ! !
Building & Co es Department
TOWN OF QUEENSBURY
FILE COP ?
TO BE COMPLETED BY BLDG. DEPT. TC W.1 OF WUC.cr4U�"
acc--77 // Application No. T i a
wn of Queeniurj -- -- - `
Permit Issued 19
BUILDING and ZONING DEPARTMENT Permit Expires 19 �." � 11 1' 1
Bay and Haviland Road, R.D. 1 Box 98 Zoning Designation fl
Queensbury, New York 12801 Variance No. Aik BUILDING & CODE DEPT.
. 1 Site Plan
;�Rev No. A
t Q Appr. e. / / �/a ' .- 8P.
71J /3 APPLICATION FOR , A _!
PUILDINR AND ZONING PERMIT 47"
* * * * * * * * * * * * * * * * * * * * * * * * * * *. *
A PERMIT MUST BE OBTAINED BEFORE BEGINNING CONSTRUCTION. ANSWER ALL OF THE FOLLOWING.
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 is:
�s:/ �rf 4IC,J_- �/ A/�GG%/9l''/
P.O. Address / I /L/= /y/G/ , {2c/ &C 2/ 7 e`e'/VS / i//S Tel. 7`/ Z.- Z /7 S
Property Location: �� '` Tax Map No.lie /3 /93.
Street number or building lot number
Subdivision name (if applicable)
THE PERSON RESPONSIBLE FOR SUPERVISION OF WORK AS REGARDS BUILDING CODES IS:
Name P.O. Address Tel. No.
Name of builder 5, /Iii: Address Tel.
Name of plumber 5/9/tifiz Address Tel.
Name of mason 5/9'lif Address Tel.
NATURE OF PROPOSED WORK: * ZONING INFORMATION:
Construction of a new building * A PLOT PLAN MUST BE PREPARED AND SUBMITTED,
yddition to a building * drawn reasonably to scale and attached hereto,
Alteration 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
*FOR DEMOLITION PERMIT, STATE SIZE AND * whether interior or corner lot. Show location
LOCATION OF STRUCTURES AFFECTED. of water supply and location and configuration
* of septic disposal area.
*
* COMPLETE INFORMATION REQUIRED BELOW.
* Size of property ft X ft.
* Existing building(s) Size ft X ft.
*
PROPOSED BUILDING AND USE:
* Existing building(s) Use
Size of new structure 2 i ft X 3C2 ft *
Foundation-pier/sla. /•artial/full * Proposed building, distance from property line
(circ e one)
No. of stories (habitable space) * Front yard ft Rear yard ft
Height (grade to ridge) /,f0 ft. * Side yards ft and ft
If residential, no, of families / * If on corner, setback from side street ft
No. of rooms(excluding baths) ye * OCCUPANCY INFORMATION
No. of bedrooms 2- *
No. of bathrooms / * PRIMARY BUILDING -
* /One family dwelling
Primary heating system 62i R ,/qi
Type of fuel * Two family dwelling
No. of fireplaces to be installed * Multiple dwelling / Number of units
Will a wood stove be installed? q/Q *
Central Air conditioning? ✓1�0 * Permanent occupancy
Transient occupancy
* Business
BUILDING STYLE, PRIMARY STRUCTURE * Industrial
Contemporary Log cabin * Other
Raised ranch Mansion Duplex * If addition, what will use be?
Split level Old style Bungalow *
Cape Cod Cottage Other * ACCESSORY BUILDING-
Colonial Row Town House * Detached garage/one car/ two car/ car
( CIRCLE ONE PLEASE ) * Attached garage/one car/ two car/ car
* * * * * * * * * * * * * * * * * * Private storage building
ESTIMATED MARKET VALUE OF * Other
CONSTRUCTION $ 3Q4_00t *
INFORMATION ON BUILDING SPECIFICATIONS, ON REVERSE SIDE OF THIS SHEET, TO BE COMPLETED!
Form BPA 4/86 and-vl
BUILDING PERMIT APPLICATION CONTINUED -
BUILDING SPECIFICATIONS:
•
Type of construction, wood frame, fire safe,etc. i/!9®J • ,91'i%.=
Will any second-hand or ungraded lumber be used? If so, for what? A/O
Foundation wall material Ole d/< Thickness /D ti
Depth of foundation below grade (to bottom of footing) lJ J
Will there be a cellar? ve, Heated or unheated? Floor sq. footage sq ft
Will there be a basement? /UQ Will any portion be used as living space? A/p
(If so, what portion? sq.ft. - - Type of use?
Type of roof - sloped/flat/shed/other f/c f/ Material. of roof 1.0,,
Size, wood studs 2 "X ( " spacing / , "o.c. length 4 ,.Ykt.
Joists(floor beams) 1st. floor 2 "X , " spacing j �' "o.c. span/p ft.
Joists (floor beams) 2nd. floor ., "X spacing "o.c. spare- ft.
Overlays(ceiling beams) 2 "X ,, " spacing /6 "o.c. span 11 ft.
Roof rafters 2 "X 9 " spacing // o.c. span / 9 ft.
Roof trusses(pre-engineered) spacing "o.c. span ft.
Exterior wall finish 5/4/diyr Of what material? Li/All
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? If so will a Fire-rated
door, enclosure, and self-closing device be provided?
Will a flue-lined chimney be installed? it./0 Height above roof ft.
Depth of chimney foundation below grade ft.
Depth of fireplace hearth ft. in.
Water supply - Municipal or private well y✓ 1
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)
Town of Queensbury AFFIDAVIT STATE OF NEW YORK
County of 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 doneion 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 work is
authorized by the owner.
SWORN TO BEFORE ME THIS Signature
owner's agent,arcnitect,contractor
_ day of 19 W
Notary Public, Warren County, N.Y.
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
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 ,
erg4„2"*%
1 . Gross floor area
2 . Type of heat (,�-t�e f °' ' ► "
3 . Is the building mechanically cooled? A,/ 0
4 . Percentage of area of windows and doors
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 414 NO �;
a. Are foundation walls insu ated? YES C ►
1 . If YES , what is the R value?
3 . Slab on grade YES NO
a. If YES , what is the devalue of insulation around
perimeter of floor?
4 . Is basement heated? YES NO
a. R value of insulation
5. Type of insulation
B. Under 161. Only
1 . it value of roof and floors exposed to ambient conditions
2 . R value of exterior walls tl\ /
3 . R value of glazed area
4 . R value of doors - '
5 . R value of floors over unheated spaces -
6. R value of slab edge insulation - unheated slab
•
7 . R value of slab insulation - heated slab
8. R value of heated basement/cellar walls (above grade)
9. R value of heated basement/cellar walls (below grade)
10. Type of insulation
C. Controls - •? 0
1. Thermostat maximum heat setting
D. Duct Systems
1 . , Is duct system installed in unheated spaces? :YEa • NO
a. If YES , R value of duct installation i• - I
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
2. Temperature control setting maximum •
C. For Swimming Pool Only
1. Maximum heating
Telephone No. 2 9' 7 gettAte-e--- '' _ nt "
(applicant ' s signature)
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 . Cross floor area I/O 62 L9 A •
2 . Type of heat
3 . Is the building mechanically cooled? //22
4 . Percentage of area of windows and doors
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 667
a. Are foundation walls insulated? YES cry
l . If YES, what is the R value?
3 . Slab on grade YES NO
7
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 . it value of roof and floors exposed to ambient conditions
2 . R value of exterior walls /Q- 025
3 . R value of glazed area 02 -5-
4 . R value of doors k • .2. .7
5 . R value of floors over unheated spaces ' Al'p2-.5
6. R value of slab edge insulation - unheated slab
7 . R value of slab insulation - .heated slab
•
B . R value of heated basement/cellar walls (above grade)
9 . R value of heated basement/cellar walls (below grade)
10. Type of insulation
C. Controls
1 . Thermostat maximum heat setting
D. Duct Systems
71 . 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 . it value of pipe insulation I TrzS✓ 6'r -1
F. Service Water Heating
1 . Performance efficiency ,� 4
2 . Temperature control setting a imum
C. For Swimming Pool Only /f/� •
1 . Maximum heating 0���
7ne No.Telephone J Z r 7 - ��%• c � � �' � � ��p
(applicant ' s signature)
f.-„„en. 4061.41
APPLICATION FOR SEPTIC DISPOSAL PERMIT
c J/
DATE / g'T
LOCATION OF PROPERTY FOR INSTALLATION
Owner's Name: gRC,/ , /``jf/l 5 Telephone: 2 9 7S
Address: a?WjeEII/1/ U'C ee j( z/ 7
Installer's Name: Telephone:
Number of bedrooms (residential only) y
Total daily flow (compute @ 150 gal per bedroom) _
Topography: circle one: Flat Rolling Steep Slope o of slope
Soil Nature: circle on San Loam Clay Other / Depth: feet
Ground Water: At what depth? feet
Bedrock or Impervious Material: At what depth? _ feet
Percolation test: circle one: not required required / rate min. inch.
Domestic water supply: circle one: Municipal Wel Other
IF domestic water supply is a Well:
Separation: Watersupply from Septic absorption / feet
PROPOSED SYSTEM: Septic Tank _gal. (minimum size: 1,000 gal.)
TILE FIELD: Each Trench 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
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
IMPORTANT
...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
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 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 $250.00.
C. An approved copy of the plot plan shall be available on the construction
site. Failure to produce said plot plan at time of inspection may result
in an immediate work stoppage.
D. Should unforeseen problems during construction prevent proper installation,
alteration or repair of an approved system, a new proposal must be submitted
to the Queensbury Building Department before further construction. .
I have read the regulations above and agree to abide by these and all requirements
of the Town of Queensbury Sanitary Sewage Disposal Ordinance.
:/" <
Signature of responsible person: � G�
Date: `//87F
Town of Queensbury
Building and Code Department
Bay at Haviland Road
Queensbury, New York 12801
(518) 792-5832
TOWN OF QUEENSBURY
BUILDING AND CODES DEPARTMENT
BAY & HAVILAND ROADS �(�
QUEENSBURY, NEW YORK 12804-
TELEPHONE (518) 792-5832
BUILDING INSPECTOR'S REPORT
REQUEST FOR INSPECTION RECEIVED 6 . I--�
NAME LA & i
LOCATION `T, - 11P
DATE - -S-CI PERMIT # R N ---j 0 1
APPROVED
YES NO
FOOTING/PIERS
MONOLITHIC POUR FORMS
FOUNDATION/DAMP-PROOFING
BACKFILL APPROVAL ,
ROUGH PLUMBING
FRAMING
ELECTRICAL ROUGH-INS
INSULATION: ''
FOUNDATION
FLOORS
WALLS
CEILING k
/FINAL INSPECTION: 5.
CHIMNEY HEIGHT
ROOFING >
SIDING N %--'
`-EXTERNAL PORCHES/STEPS L. /
STAIRS-CLEARANCE & RAILS er,
PLUMBING FIX frfTURES/RELIEF VA VE %./
INTERIOR TRIM/PRIVACY DOORS t �`
FINISHED FLOORS q L./.N. _
GARAGE FIREPROOFING \ i-,DOOR CLO$ER(S) \ N f p
SMOKE DE2'ECTORS \
FINAL ELEC RICAL INSPECTION i/
FINAL APPR VAL OF CONSTRUCTION
A SIGNED CERTIFICATE OF OCCUPANCY MUST BE
OBTAINED FROM THE BUILDING DEPARTMENT BEFORE
THESE PREMISES ARE OCCUPIED!
REMARKS:
o ,�, 11&4-T — 1311gs
Oti;�� �s� 4°
it\1.1
INSPECTOR
// k6
TOWN OF QUEENSBURY
BUILDING AND CODES DEPARTMENT �jj a,e
BAY & HAVILAND ROADS Lit 1S t
QUEENSBURY, NEW YORK 12801 4 '"tera " 9eS
TELEPHONE (518) 792-5832
BUILDING INSPECTOR'S REPORT REQUEST FOR INSPECTION RECEIVED /1` q p
NAME _ �� / ✓� 75
LOCATION /, g(../ / 4
DATE `/-qxy PERMIT # fJ "", Fo
APPROVED
YES NO
FOOTING/PIERS
MONOLITHIC POUR FORMS
FOUNDATION/DAMP-PROOFING
BACKFILL APPROVAL
ROUGH PLUMBING
FRAMING
E4OTRICAL ROUGH-IN
SULATION:
FOUNDATION
FLOORS
WALLS
CEILING
FINAL INSPECTION:
CHIMNEY HEIGHT �<
ROOFING
SIDING
EXTERNAL PORCHES/STEPS
STAIRS-CLEARANCE & RAMS
PLUMBING FIXTURES/RELIEF VALVE
INTERIOR TRIM/PRIVACY DOORS '•,
FINISHED FLOORS /
GARAGE FIREPROOFING'
DOOR CLOSER(S)
SMOKE DETECTORS
FINAL ELECTRICANSPECTION
FINAL APPROVAL OF CONSTRUCTION ;
1
A SIGNED CERTIFICATE OF OCCUPANCY MUST BE
OBTAINED FROM THE BUILDING DEPARTMENT BEFORE
THESE PREMISES ARE OCCUPIED!
REMARKS:
&149-S\
INSPECTOR
J ,tt
��g cc�� //
_own of Queen3buri
BUILDING and ZONING DEPARTMENT
Bay and Haviland Road, R.D. 1 Box 98
Queensbury, New York 12801
BUILDING INSPECTOR' S REPORT
NAME 4(461. (42(. L/2
LOCATION �. „ i-c &..
Date f/g9/ if Permit No.
* * * * * * * * * * * * * * * * * * * * * * *
✓ = APPROVED - YES / NO
Footing/Pier Forms
Foundation
Waterproofing
Backfill /
2ami ng 1/"
Roofing
Siding
Masonry Veneer
Rough Plumbing
Relief Valves
Ext. Porches
Finished Floors
Interior Trim
Stairs & Railings
Cellar Drain Tile
Concrete Floors
Plbg. Fixtures
Gar. Fireproofin,-
Door Closers
Smoke Detector:
Chimney
INSULATION:
Foundation
Floors
Walls
Ceiling
FINAL ELECTRICAL INSPECTION
DRIVEWAY/APPROVAL
Final B ilding Survey
Next sctieduled inspection (call when ready)
Remarks-
Building spector
6/86 and-vl
awn of QUeQfliarf,
BUILDING and ZONING DEPARTMENT
Bay and Haviland Road, R.D. 1 Box 98
(71/1 Queensbury, New York 12801
BUILDING INSPECTOR' S REPORT
NAME /54,4 a, /j
LOCATION 44 le: : CS-ff'
Date -/, / Permit No. iaror -
* * * * * * * * * * * * * * * * * * * * O* *
✓ = APPROVED - YE// NO
4 noting/Pier Forms �,f' ��/ '-
Foundation
Waterproofing
Backfill
Framing
Roofing
Siding
Masonry Veneer
Rough Plumbing
Relief Valves
Ext. Porches
Finished Floors
Interior Trim
Stairs & Railings
Cellar Drain Tile
Concrete Floors
Plbg. Fixtures
Gar. Fireproofi g
Door Closers
Smoke Detecto•
Chimney
INSULATION:
Foundation
Floors
Walls
Ceiling
FINAL ELECTRICA NSPECTION
DRIVEWAY APPROVAL
Final Building Survey
Next scheduled inspection (call when ready)
Remarks-
'
t
Bu. di g Inspector
6/86 and-vl
klAd
own o0Queeniur
f y
ILDING and ZONING DEPARTMENT
1 i 0/r Bay and Haviland Road, R.D. 1 Box 98
/�f , Queensbury, New York 12801
BUILDING INSPECTOR ' S REPORT
NAME
LOCATION jam, 4/7/i6/ . J
Date$-/8 /8&" Permit No. .gpi;a,901
* * * * * * * * * * * * * * * * * * * * * * *
✓ - APPROVED - YES / NO
Footing/Pier Forms
Foundation
Waterproofing
ackfill
Framing
Roofing
Siding
Masonry Veneer
Rough Plumbing
Relief Valves
Ext. Porches
Finished Floors
Interior Trim
Stairs & Railings
Cellar Drain Tile
Concrete Floors
Plbg. Fixtures
Gar. Fireproof' g
Door Closers
Smoke Detecto s
Chimney
INSULATION:
Foundation
Floors
Walls
Ceiling
FINAL ELECT kAL INSPECTION
•
DRIVEWAY APPROVAL
Final Building Survey
Next scheduled inspection (call when ready)
Remarks-
B ' ing Inspector
hiL6 and-v
Jown of Queensburcy
BUILDING and ZONING DEPARTMENT
y and Haviland Road, R.D. 1 Box 98
r(/n
Queensbury, New York 12801
SEPTIC DISPOSAL SYSTEM INSPECTION
NAME tl},,_fliZiim4
LOCATION �,.f l— 4:4
DATE Lr/3/ 15" PERMIT NO., J,1 it"361
SOIL TYPE - Sand - Loam - Clay -
Percolation Test Required? YES - NO
Percolation rate - Min/Inch
TYPE of SYSTEM:
Absorption field, total length 1
Length of each trench
Depth of trenches
Size of gravel �/
SEEPAGE PITS{N ‘•er of)
Size- ft. X \ ft.
Gravel size
PIPING: Size Type
Bldg. to tank
Tank to dist. box
Dist. box to field/pi-
Openings sealed? Y' S NO Partial
LOCATION/SEPARATI. S:
Foundation to to,k ft.
Foundation to a.sorption ft.
Absorption to . ot line ft.
Separation of pits ft.
LOCATION OF' '.YSTEM ON PROPERT', (circle one)
Front - Rea - Left side - Rigit side -
COMMENTS: / C�e�
/ /4 ;j O.
k I0 ` arm7. .,
SYSTEM USE APPROVED (IIIPNO
J4J
• d /
Buil4 in- V ns.ector
01/86 and vl
MAIN OFFICE ATLANTIC-INLAND, INC.
997 McLean Rd. NEW YORK
Cortland,New York 13045
MEMBER OF N.F.P.A.AND I.A.E.1.
Phone: (607)753-7118 FIRE UNDERWRITERS 225 67
(607)753-7809
(607)753-1396 (Electrical and Fire Inspection-Enforcing and Consulting Service)
(Incorporated in the State of New York)
Desiring Certificate of Approval,application is made for inspection of electrical installation in the premises described below.On demand applicant agrees to pay for
inspection service in accord with schedule of charges.
APPLICATION FOR ELECTRICAL INSPECTION —PLEASE PRINT OR TYPE
THIS SECTION TO BE COMPLETED BY/ APPLICANT DATE OF APPLICATION b .7e 0
CITY.TOWN,VILLAGE e`�'j f F�<<5 COUNTY 47/, alEA/ , STATE /U
STREET ^
ADDRESS aG( , ��.e. y/11 69dr ,igB 7/7 BUILDG.NO.
RURAL
DIRECTIONS POLE NO.
OWNER'S J /
NAME rah /[✓r A//u ,/7_d
,1 c OCCUPIED AS
OCCUPANT f"g_j BUILDING—New❑Old❑WORK—New❑Additional 0
OWNER'S P.O.
ADDRESS I/9lMt.
APP.FOR—ROUGH WIRING IW TURES 0 OR READY FOR INSPECTION 19
FEE REMITTED—S BY CHECK 0 CASH 0 MONEY ORDER 0 MAKE PAYABLE TO ATLANTIC-INLAND,INC—NEW YORK
Number of Hough Wiring Outlets Fixtures Add Installation
Swtch LPtng Recap. KW Med. Mogul Fluor. 500 750 1000 1250 1500 1750 2000 2250 2500 2750 3000
Heat Base Base
Elect Heat
Amp.Service Water Htr. Burner Air Cond.
Surface Unit Oven Range Gr.Disp. Dish W.
Dryer H.P.Pump Ex.Fan Hood
OTHER EQUIPMENT(Specify Type&Capacities)
•
TYPE OF SIZE OF SUB- BRANCHES NO.OF
WIRING OPEN 0 CONCEALED 0 OTHER MAIN MAIN BRANCHES
/� ) CIRCUITS
U SIGNATURES OV') 4c G C. ie/`llice-. 9 LICENSE p PERMIT M
APPLICANT'S NAME OF
ADDRESS ! ^
ifilUTILITY
OFFICE TO
CITY STATE ZIP CODE BE NOTIFIED
• . SPACE:BELOW FOR USE OF INSPECTORS ONLY'
ROUGH WIRING AMP SERVICE K.W.SURFACE
OUTLETS _ EQUIPMENT UNIT
SWrrCHES AMP SERVICE K.W.OVEN
CONDUCTORS
H.P.GAHRAGE
RECEPTACLES H.P.PUMP DISPOSAL IJNIT
MEDIUM BASE
K.W.
FIXTURES K.W.DRYER DISHWASHER
MOGUL BASE K.W.WATER
FIXTURES HEATER K.W.RANGE
FLUORESCENT H.P.AIR AMP. RECEPTACLES
FIXTURES CONDiTIONER
MERCURY VAPOR OR WIRING 8 CONTROLS FOR BURNER SMOKE FRAC.H.P.
QUARTZ FIXTURES DETECTORS VENT FANS
MOTORS.H.P. 1/20 1/12 1/10 1/6 1/6 1/4 1/3 1/2 3/4 1 11/2 2 3 5 7/ 10 15 20 25 30 40 50 75 100
MARK NUMBER
OF EACH SIZE
-. 500 750 1000 1250 1500 1750 2000 2250 2500 2750 3000
APPARATUS Elect.Heat
MISC.INFO. Received FEE PAID
Inspected
❑PROGRESS
r TOTALS
Stanley Matyka CI DEFECTIVE
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!1 ❑Rough Wiring Certificate
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D '. 2, Box 60 0 Temporary Service Money Order
Greenwich, N.Y. 12834 ❑FINAL CERTIFICATE
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(518) 638-6339 0 Dup.Cert.Req.
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