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88-633 CERTIFICATE OF OCCUPANCY 1 TOWN OF QUEENSBURY WARREN COUNTY, NEW YORK Date May 23, 19 89 This is to certify that work requested to be done as shown by Permit No. 88-633 has been completed. This structure may be occupied as a One Family Dwelling Location Lot 85 Hidden Mill Dr, (St. No. 53) Hidden H111_s SlIbil, Owner Stephen Ma belly By Order Town Board TOWN OF QUEENSBURY Building & Zoning Inspector BUILDING PERMIT TOWN OF QUEENSBURY , No. 88-633 0 WARREN COUNTY, NEW YORK PERMISSION is hereby granted to Stephen M. Kelly I OWNER of property located at Lot 85 Hidden Hills Dr. (St. No. 53) Street,Road or Ave. Hidden Hills Subd. 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 rcar approved and in compliance with the Town of Queensbury Building and Zoning Ordinance. b _ m 1. OWNER'S Address is 15 Willow Rd. Glens Falls, N.Y. 12801 m 2. CONTRACTOR or BUI LDER'S Name Same 3. CONTRACTOR or BUILDER'S Address r 0 Sasme rt a lr x 4. ARCHITECT'S Name R a 0 r 5. ARCHITECT'S Address F W C rt 6. TYPE of Construction—(Please indicate by X) rt (X)Wood Frame ( ) Masonry ( ) Steel ( ) L C 7. PLANS and Specifications No. 26' X 50' as per plot plan, specifications and application including septic system and attached two—car garage. 8. Proposed Use One Family Dwelling r w F 5.00 C/O Cr. F- G $ 136.00 PERMIT FEE PAID —THIS PERMIT EXPIRES March 1 19 89 d � (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.) F- Dated at the Town of Queensbur his 25th Day of August 19 88 SIGNED BY for the Town of Queensbury Building and Zoni Inspector c TO BE COMPLETED BY BLDG. DEPT. Application No_ 1-�n 7OW-11 o/ QueeiiJlury Permit Issued 19 TOV.'N OFF QUE"Ft S'r!:f:'i BUILDING and ZONING DEPARTMENT Permit Expires 19 D i Bay and Haviland Road, R.D. 1 Box 98 Zoning Designati9 n ` 7-49 Queensbury, New York 12801 Variance No. A"11 Site Plan Devi w No. JUN 1 � Approv .. by.- UIL I �3c CODE DEF (' APPLICATION FOR ►��1" �1 HILDING AND ZONING PERMIT # 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: , /1 /'"C'/// P.O. Address /,<­ 1111/64j j-5ona ,_ G/r�.7,} /=7 -//j /v ,v _Tel. 2f3--3o-z__ Property Location: Tax Map No.—/—/— Street number or building lot number Subdivision name (if applicable) '`41d/1l,, 111//5 THE PERSON RESPONSIBLE FOR SUPERVISION OF WORK AS REGARDS BUILDING CODES IS: m X/C#y ��0� G/Phs ffi/�c 7 P3- �z Name P.O. Address Tel. No. Name of builder Stern 2 Address Tel. Name of plumber Syti, Address Tel. Name of mason Si✓hi Address Tel. 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, _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 dumber or lot number and indicate FOR DEMOLITION PERMIT, STATE SIZE AND * whether interior or corner lot. Show location of water supply and location and configuration LOCATION OF STRUCTURES AFFECTED. * of septic disposal area. * COMPLETE INFORMATION REQUIRED BELOW. * Size of property ///) ft X /120 ft_ * Existing building(s) Size ft X ft. * PROPOSED BUILDING AND USE: * Existing building (s) Use Size of new structure 46 _ft XSD ft Fcsundation-pier/slab/crawl/partial/ ' Proposed bui di g, distance from prope line (circle one) * Front yard ,� �� t Rear yard O ft No. of stories (habitable space) * Side yards o ft and ft Height (grade to ridge) a0 _ ft. * If on corner, d!t, k from side street ft If residential, no. of families / No. of rooms(excluding baths) * OCCU ANCY INFORMATION No. of. bedrooms `t" No. of bathrooms a '/Z * PRIMARY BUILDING - Primar 'heating system * One family- dwelling Y 2_ Gi�c `�d� i4 — * Two family dwelling 'Type of. fuel ��?� _ _ No. of .fireplaces to be installed ; * Multiple dwelling / Number of units Will a wood stove be installed? A, * Permanent occupancy Central Air- cendi_tioni.ng: n� �� * __Pr�ansient occupancy * Business BUILDING STYLE, PRIMARY STRUCTURE ,. --Industrial * —Other Ranch ('nntamnnrary T.nrr onhi n { BUILDING PERMIT APPLICATION CONTINUED BUILDING SPECIFICATIONS: Type of construction, wood frame, fire safe,etc. Glioo «A1� Will any second-hand or ungraded lumber be used? If so, for what? A/O Foundation wall material A-Ir-4 )DOtal-17 ��/f G� Ifhic'lness Depth of foundation below grade (to bottom.of footing) Will there be' a cellar? Heated or unheated? K Floor sq. footage /goa sq ft Will there be a basement? _Will any portion be used as living space? A c (If so, what portion? sq.ft. - - Type of use? Type of roof - sloped flat/shed/other Material. of roof FPS=,t lnss Sh�h s 1 P� Size, wood stu sue_"X " spacing_ "o.c. length ft. Joists(floor beams) 1st. floor P "X p/i spacings"o.c. spanis ft. Joists (floor beams) 2nd. floor "X It spacing iG "o.c. span is ft. Overlays(ceiling beams) "X " spacing "o.c. span_ ft. Roof rafters "X of spacing 1_L o..c. span ft. Roof trusses(pre-engineered) spacing_,&,y_"o.c. span 4(, ft. Exterior wall finish Of what material? L 1 n y/ Interior wall finish gcc'Y If a garage is to be attached, describe materials to be used for FIRE SEPARATION: i--1 R P- /1p'+ ed sX ee F .Pe cff Is there to be an opening between garage and dwelling? If so will a Fire-rated door, enclosure, and self-closing device be provided? U FS Will a flue-lined chimney be installed? /L1, Height above roof ft. Depth of chimney foundation below grade ft. Depth of fireplace hearth ft. in. Water supply - Municipal or private well Mtt/9 / c +'-'V 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 A F F I D A V I T County of Warren STATE OF NEW YORK 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 donelon 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 _ I _ �------------------ Owner, owner's ge�t�'�rcniLect;contractor day of 19 Notary Public, Warren County, N.Y. SPECIAL CONDITIONS OF THE PERMIT: TOWN OF QUEENSDURY WARREN COUNTY, NEW .YORK Application fo.r : BUILDING -PERMIT IN COMPLIANCE WITH THE NEW YORK STATE ENERGY CONSERVA.T-1-ON-CODE A permit must be'o`btain�d before beginning work. ANSWER ALL of the following:) 1 . Gross floor area 2 . Type of heat 3 . Is the building mechanically cooled? A . 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 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 D. Under 169, Only - 1 . R value of roof and floor exposed to ambient conditions_ ?j ID -2 R .value of exterior walls 3 . R value of glazed area 4 . R value of doors \ ► ( 5 . R value of floors over unheated spaces_ ' �`Z5 6 . R value of slab edge insulation - unheated slab 7 . R value of slab insulation -heated slab © . 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 1 . I-s. duct system installed in unheated spaces? ;'ES NO- a. If YES , R value of duct installation b. It value of duct in other areas E. Piping Insulation 1 . Size of hot -water or cooling carrying agent pipe .1 APPLICATION FOR'SEPTIC DISPOSAL PERMIT DATE LOCATION OF PROPERTY FOR INSTALLATION a �S Owner's Name: S fe,/of P "t, / Telephone: Address: /S A/ ///C.,' )e Installer's Name: )Qe d C'P�¢ /� �` Telephone: 7 f2 Number of bedrooms (residential only) Total daily flow (compute @ 150 gal per bedroom) a 'Topography: circle one: Fla Rolling Steep Slope % of slope Soil Nature: circle one San Loam Clay Other / Depth: feet Ground Water: At what fiepth? 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 , Well 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 �.1 Size of stone to be used Depth or Thickness feet IMPORTANT ...Please...LIST NEW EQiAPMENT 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. 1 have read the regulations above and agree to abide by these and all requirements of the Town of Queensbury Sanitary Sewa Disiposal Ordinance. Signature of responsible person: r.--� �Z l Date: 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 NAME LOCATION DATE - - PERMIT APPROVED YES NO FOOTING/PIERS MONOLITHIC POUR FORMS FOUNDATION/DAMP-PROOFING BACKFILL `APPROVAL ROUGH PLUMBING FRAMING S ELECTRICAL ROUGH-IN INSULATION: FOUNDATION r FLOORS WALLS fCEILING --P NAL INSPECTION: Lela, CHIMNEY HEIGHT ; ROOFING J` SIDING b' EXTERNAL PORCHES%STEPS STAIRS-CLEARANCE & RAILS PLUMBING FIXTURES/RELIEF, VALVE INTERIOR TRIM/PRIVACY DOORS FINISHED FLOORS GARAGE FIREPROOFING DOOR CLOSERr'(S) SMOKE DETECTORS FINAL ELECTRICAL INSPECTION FINAL APPROVAL OF CONSTRUCTION A SIGNED CERTIFICATE OF OCCUPANCY MUST BE OBTAINED FROM THE BUILDING DEPARTMENT BEFORE THESE PREMISES ARE OCCUPIED!- REMARKS: T7V.4PFrrpn77 •uflsf`�JM J�vv�� v VJ vJ�vJ 'V J�Rv J�v vJ lip MIDDLE MIDDLE DEPARTMENT INSPECTION AGENCY, INC. 900,Haddon Aaenue`Collingswood N.J 08108 C °` cats. May 9, 1989 � Certif leg that the eleCtrlcal equipment listed has been examined and'is approved as being in accord with the National Electrical�Code, applicable governmental utility andAgency rules. C ' Owner: Steve Kelly ? i %; Occu anc li l't i I l i 1 1 p w, Dwel ng t t C 1` LJt Single Fam 'Occupant: g } y 1' Location: Lot 85 Hiddeni Hil11sl; Queerisbiiry_(Warren.._Co)___ ,'s-'certificate covers thinelectrical equipment and installation inspected this C date. If additional egwpmentishould be introduced or alterations made to existing system th,5 certificate shell be null and void, and application for 120 Outlets 6 i `Receptacles 30 Fixt;ures, inspection should besubmdteapr"omptlyto this Agency. C ,7 Equipment: ° ?).ls: y '- s(1 I;'�rj�.,(=Holder of this certificate should present same to his property insurance carrier C u,�L`i c- L�:....1, ,,l w:.S ,c_, 200 Amp Service,. 6` Appliances (agent or company)as evidenceotcertificationof electrical equipment approved '� as specified. F— Kelly Electric', 141 ,n } Applicant: Willow Road pp Queensbury, NY 12804 ~ X NO. 1 5-0 20410 C Form No.703 EL 1-83 - �J TOWN OF QUEENSBURY BUILDING AND CODES DEPARTMENT BAY & HAVILAND 'iROADS QUEENSBURY, NEW YORK 12801 TELEPHONE (518) 792-5832 i BUILDING INSPECTOR'S REPORT REQUEST FOR INSPECTION RECEIVED NAME LOCATION DATE _PERMIT # APPROVED YES NO FOOTINGIPIERS MONOLITHIC POUR FORMS FOUNDATIONIDAMP-PROOFING BACKFILL APPROVAL ROUGH PLUMBING FRAMING, ELECTRICAL ROUGH-IN ,, SULATION: FOUNDATION FLOORS WALLS CEILING j FINAL INSPECTION: CHIMNEY HEIGHT ROOFING SIDING '@A EXTERNAL PORCHES/STEPS STAIRS-CLEARANCE�� f RAILS PLUMBING FIXTURESIRELIEF VALVE INTERIOR TRIMIPRIVAGY DOORS FINISHED FLOORS1 GARAGE FIREPROOFING DOOR CLOSER(S)rf SMOKE DETECTORS FINAL ELECTRICAL'INSPECTION, FINAL APPROVALiOF CONSTRUCTION i f r A SIGNED CERTIFICATE OF OCCUPANCY MUST BE OBTAINED FROM THE BUILDING DEPARTMENT BEFORE THESE PREMISE'S ARE OCCUPIED!' f REMARKS: I I _ f 7717Q D Ll/ nD TOWN OF QUEENSBURY BUILDING AND CODES DEPARTMENT BAY & HAVILAND ROADS QUEENSBURY, INEW YORK 12809- TELEPHONE (518) 792-5832 i BUILDING INSPECTOR'S REPORT REQUEST ?51 RECEIVED/ NAME lll"` LOCATION t DATE PERMIT # PPROVED YES NO FOOTING/PIERS MONOLITHIC POUR FORMS FOUNDATION/DAMP-PROOFING BACKFILL APPROVAL ROUGH PLUMBING FRAMING ELECTRICAL ROUGH=IN INSULATION: FOUNDATION FLOORS WALLS CEILING FINAL INSPECTION: CHIMNEY HEIGHT ROOFING SIDING EXTERNAL PORCHES/STEPS STAIRS-CLEARANCE & RAILS,., PLUMBING FIXTURESIRELIEF VALVE INTERIOR TRIMIPRIVACY DOORS FINISHED FLOORS GARAGE FIREPROOFING'' DOOR CLOSER(S) SMOKE DETECTORS FINAL ELECTRICAL INSPECTION FINAL APPROVAL OF,riCONSTRUCTION * f A SIGNED CERTIFICATE OF OCCUPANCY MUST BE OBTAINED FROM THE BUILDING DEPARTMENT BEFORE THESE PREMISES ARE OCCUPIED! REMARKS: I I INSPECTOR OF QUEENSBURY )ING AND CODES DEPARTMENT & HAVILAND ROADS ENSBURY, NEW YORK 1280-Q- LEPHONE (518) 792-5832 BUILDING INSPECTOR'S REPORT REQUEST FOR INSPECTION RECEIVED- C� - NAME LOCATION M DATE - - PERMIT # APPROVED YES NO FOOTING/PIERS MONOLITHIC POUR FORMS FOUNDATION/DAMP-PROOFING BACKFILL APPROVAL ROUGH PLUMBING, FRAMING ELECTRICAL ROUG97IN INSULATION: rF FOUNDATION FLOORS WALLS CEILING P FINAL INSPECTION: CHIMNEY HEIGHT ROOFING SIDING EXTERNAL PORCHES/STEPS t STAIRS-CLEARANCE & RAILS PLUMBING FIXTURES/RELIEF VALUE INTERIOR TRIM%PRIVACY DOORS FINISHED FLOORS GARAGE FIREPROOFING DOOR CLOSER.,(S) r SMOKE DETECTORS FINAL ELECTRICAL INSPECTION FINAL APPROVAL OF CONSTRUCTION " A SIGNED CERTIFICATE OF OCCUPANCY MUST BE OBTAINED F�OM THE BUILDING DEPARTMENT BEFORE THESE PREM{SES ARE OCCUPIED! REMARKS: ��: UtiJ INS u!/3 ouas *CTOR( _loom o f QueenjLry BUILDING and ZONING DEPARTMENT Bay and Haviland Road, R.D. 1 Box 98 Queensbury, New York 12801 SEPTIC DISPOSAL SYSTEM INSPECTION NAME LOCAT I ONA0 DATE_ PERMIT NO. SOIL TYPE Sand - Loam - Clay - Percolation Required? YES - Percolation rate - Min/Inch - TYPE of SYSTEM: Absorption field, tot 1 length ' Length of each•L t ch Depth of t c yes Size gravel_ SEEPAGE PITS4Number of) Size- —Sc�-ft. X ft. Gravel size ,? PIPING: Size T pe Bldg. to tank (lt— Tank to dist. box -1 L/ Dist. box to f-iattT/-pit I ') Openings sealed? YES , NO Partial LOCATION/SEPARAT,•I✓ONS: Foundation to tank ?: ft. Foundation to ;.absorption ftt— Absorption to''lot line Q< ft. Separation of pits �"1,/L ft. LOCATION OF//SYSTEM ON PROPERTY,(circle one) Front - ea - eft si e - Right side - COMMENTS:/ I t� I� js SYSTEM USE APPROVED YE NO Pt7-� Building Inspect r 01/86 and 'vl 7 Jown of QueenjLry . BUILDING and ZONING DEPARTMENT Bay and Haviland Road, R.D. 1 Box 98 Queensbury, New York 12801 BUILDING INSPECTOR ' S REPORT NAME,- LOCATION Date/ / Permit No. * * * * * * * * * * * * * * * * * * * * * * * ✓ = APPROVED - YES / NO Footing/Pier Forms Foundation Waterproofing �,eackfill Framing Roofing Siding 4 Masonry Veneer Rough Plumbing l Relief Valves Ext. Porches i Finished Floors ',.' tF, Interior Trim Stairs & Railings'' Cellar Drain Tile Concrete Floors Plbg. Fixtures Gar. Fireproofing '>. Door Closers , Smoke Detectors { Chimney INSULATION: Foundation Floors Walls Ceiling FINAL ELECTRICAL INSPECTION DRIVEWAY APPROVAL Final Building Survey Next scheduled inspection (call when ready) Remark®'J � Bbilding InQector 6/86 and-vl lAr TOWN OF QUEENSBURY BUILDING AND CODES DEPARTMENT ��- BAY & HAVILAND ROADS QUEENSBURY, NEW YORK 12801 TELEPHONE (518) 792-5832 BUILDING INSPECTOR'S REPORT REQUEST FOR INSPECTION RECEIVED / �7-45 NAME LOCATION �� j �L^�%U/�IZ7 _/ DATE PERMIT # APPROVED YES, NO OTING/PIERS MONOLITHIC POUR FORMS FOUNDATION/DAMP-PROOFING BACKFILL APPROVAL ROUGH PLUMBING FRAMING ELECTRICAL ROUGH-IN r INSULATION: FOUNDATION FLOORS WALLS CEILING FINAL INSPECTION: CHIMNEY HEIGHT ROOFING SIDING EXTERNAL PORCHES/STEPS STAIRS-CLEARANCE & RAILS PLUMBING FIXTURES/RELIEF VALVE INTERIOR TRIM/PRIVACY DOORS FINISHED FLOORS GARAGE FIREPROOFING DOOR CLOSER(S) SMOKE DEWECTORS FINAL ELECTRICAL INSPECTION FINAL APPROVAL OF CONSTRUCTION ' A SIGNED CERTIFICATE OF OCCUPANCY MUST BE OBTAINED FROM THE BUILDING DEPARTMENT BEFORE THESE PREMISES ARE OCCUPIED!- REMARKS: TN.SpFrmnQ TOWN OF QUEENSBURY BUILDING AND CODES DEPARTMENT BAY & HAVILAND ROADS QUEENSBURY, NEW YORK 1280!!� TELEPHONE (518) 792-5832 BUILDING INSPECTOR'S REPORT REQUEST FOR INSPECTION RECEIVED NAME , LOCATION �Q ---------- DATE PERMIT # APPROVED YES NO FOOTING/PIERS MONOLITHIC POUR FORMS FOUNDATIQN/DAMP-PROOFING BACKFILL \APPROVAL ROUGH PLUMBING FRAMING \ ELECTRICAL ROUGH-IN ' INSULATION: FOUNDATION , FLOORS ' WALLS ILING ' F NAL INSPECTION-', CHIMNEY HEIGHT , ROOFING SIDING ° F EXTERNAL PORCHES/STEPS STAIRS-CLEARANCE & RAILS PLUMBING FIXTURES/RELIEF VALVE f/ INTERIOR T.4IM/PRIVACY DOORS FINISHED b?LOORS GARAGE FIREPROOFING f/ DOOR CLO$ER(S) SMOKE DETECTORS FINAL "ELECTRICAL INSPECTION FINAL APP OVAL OF CONSTRUCTION A SIGNED CERTIFICATE OF OCCUPANCY MUST BE OBTAINED FROM THE BUILDING DEPARTMENT BEFORE THESE PREMISES ARE OCCUPIED! REMARKS: TOt,'N OF OU FFNS BU' RY BUILDIAC .DFPAP.T,MFNT -3 BUILDING PFRMIT RFQUIRFMFNTS CHFCK LIST Where" not";applicable indicate by NA l.•;. Type :of permit requested A Construction of- new building B Construction of addition or alteration •-C.. .Sewage D . Sig:n F Other. 2. . Required documents submitted :' Yes No If'=not check further documents req ui ed. A....Plot plan is required B Building Plans C Sewage D Other 3. Required Zoning Regulations: Zone Classification A. Ls use specifically allowed in - zone: Yes No 1. Check applicable explanation a. -Permitted Principal b. Requires Site Plan Review, Type I Type II c. Preexisting non-conforming use or expansion "thereof B. Is;. lot size. adequate? Yes No 1 . Preexisting -non-conforming lot 2. Lot "size meets required sq. ft. 3. Lot meets, width and depth requirements C.` I "Lot , has required frontage on Public Road. Yes No 1. If not, explain. D•.. Required off-street parking. Yes _ No T. Residence only is ther'e the required minimum Sq.' ft: Yeses No F.; Are- proper setbacks met. ' Yes No If `not, .explain. G. Required permeable area " is Adequate Inadequate H. Hu"ilding height Does Does not exceed the- maximum. Form 8-82b MIDDLE DEPARTMENT•INSPECTION AGENCY, INC. National Headquarters \ 900 Haddon Ave., Collingswood, N.J. 08108 Date:S�S' City, Town or Township C1 E P17 C Cry�/ QQ County l•�b/�•O Pam, State / / Location/Address G U S Ql / G�� (If Located in Rural Area- Please Attach Directions) Pole # Owner S��G� Ph, 1:7p Permit # Occupied As ra s /o h ,r� /,�Fsi�/�y f�/ Building: New❑ Old❑ Occupant Work Area in Building (Floor #,etc.): App. for: Wiring Service® or: Ready for Inspection: Fee Remitted-$ Cash❑ Check❑ • M.O. ❑ Make Payable To: M.D.LA. Number of Rough Wiring Outlets Elect. Heat 500 7so loon lzso 1500 17so 2000 2zso z5oo 2750 3000 Switches Lighting Amp. Service Surface Unit Dishwasher Range Receptacles Water Heater Air Conditioner Dryer Pump Number of Fixtures Oven Garbage Disposal Wiring and Controls for Burner Amp. Receptacles Fractional H.P. Vent Fans Other Equipment: MOTORS H.P. 1/zol/1z 1/1a 1/8 1/6 1/4 1/3 1/2 3/4 1 11/z .2 - 3 5 71/2 10 15 20 25 30 40 50 75 100 Mark Number of Each Size Applicant's r 1 Signature License # Permit # T/A - / Utility: Applicant's Address: �� i�,l�i s /�OfL�c� (NAME) (OFFICE LOCATION (City)-0 fr,Ily T�/ls (State) /a gG/ /V� (Zip) Service Request # "NoticecaLaobel �/3— ? z z Electrician: ,C- �r?c. / . DATE RECEIVED: DATE INSPECTED: : Same as Above[:] or: ❑ 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 MOT RS H.P. 1/20 1/12 1/10 1/8 1/6 1/4 1/3 1/2 3/4 1 1!/z 2 3 5 74z 10 15 20 25 30 40 50 75 100 � d� p�}F1Ck J ➢�5h�i3r -`— ?0 BOX 321 •rludson Fills, Act. Heat 500 750 3000 1250 1500 1750 2000 2250 2500 2750 3000 513/793-34731 339 ELECTR"CAL IPiSPECTOR CERTIFICATIONS. USE FOR INITIAL VISIT.ONLY. NOTIFIED DATE CORRECT.FEE FEE PAID ❑ RW Progress: Inc.❑ LKD❑ Contractor ❑ CFT Violation: Work Comp.❑ Inc. ❑ ❑ LIA � Owner CASH ❑ ❑ L/A - Fee CHK # Due MO # ❑ IPA Municipal INV # Date: Other Side❑ ` Utility Applicant El Owner ❑ Cut in Card ❑ Temp # Date ❑ Final # Date INSPECTORS SIGNATURE APPLICATION FORM NO.250 EL 11186