Loading...
2002-272 TOWN OF QtEENSBURY 742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201 Community Development-Building&Codes (518)761-8256 TIFIrATE OF CEARV Permit Number: P20020272 Date Issued: Tuesday,December 24,2002 This is to certify that work requested to be done as shown by Permit Number P20020272 has been completed. Tax Map Number: 523400-290-000-0001-046.000-0000 Location: 275 CHESTNUT RIDGE RD,Eh W. Owner: EDWARD&JOAN SMITH Applicant: EDWARD&JOAN SMITH This structure may be occupied as a: By Otder of Town Board Fireplace TOWN OF QUEENSBURY Garage-3 Cars Attached Single Family Dwelling Director of Building&Code nforc ent i TOWN OF QUEENSBURY 742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201 i: Community Developm.etit=Buil'cling& Codes (518) 761=8256 ' 'BUILDING PERMIT Permit Number: P20020272 Application Number: A20020272 Tax Map No: 523400-290-000-0001r= -000-0000 Pertnission is hereby granted to: EDWARD &JOAN SMITH For property locateclf`at: 275 CHESTNUT RIDGE RD. EA W. in the Town.of Queensbury, to construct ot.place; at the above location in accordance With,application together with plot plans and other infomation hereto filed and approved and in compliance with.the NYS Unifaxm Zoning Building Codes and the Queensbury Zong Ordinance. TWe of Construction Value Owner Address: EDWARD &JOAN SMITH Fireplace PO BOX 931 Garage-3 Cars-Attached BOLTON LANDING,NY 12814-000 Single Family Dwelling 385;000.00 Total Value 395,000.00 Contractor or Builder's Name/ Address Electrical Inspection Agency COLLETTE CONSTRUCTION COMMONWEALTH ELECTRICAL At 9 COLLETTE LANE PO BOX 706 HUDSON FALLS.NEW YORK HAGUE,NY Plans &Specifications 2002-272 3322 SQ FT;SINGLE FAMILY DWELLING WITH 3-CAR ATTACHED GARAGE AND 2 FIREPLACES AS PER PLOT PLAN SPECIFICATIONS $472.24 PERMIT FEE PAID - THIS PERMIT EXPIRES: Thursday,May 01,2003 (If a longer period is required,an application for an extension must be made to the code Enforcement Officer of the Town of Queensbury before the expiration date.) Dated at theTo of en ury day,May 01,2002 SIGNED BY for the Town of Queensbury. Director of Building&Code Enforcement r Building Permit Application Town of Queensbury—Dept of Community Development,742 Bay Road,Queensbury,NY (518)761-8256 A permit must be obtained bef6re beginning construction. Permit File N No inspection will be made until applicant has received a Fee Paid $ valid building permit. All applicants' spaces on this Rec. Fee Paid application must be completed and must appear on the Reviewed By- application form. Applicant: to 76�11 Owner: E-CO 91 �/Alj S1111, Address: �5` /'/-Zovt/7' -7r, Address: 6,4 4 Phone# Phone# Property Location: Lot Number: 1 House Number Subdivision Name: Tax Map Numben, XNew Building: reside c /commercial Estimated Market Value'of Construction: $ E3 Addition: lres�leoc.I commercial an If Addition,what will use of new addition be? o Alteration: residence/ commercial * 0 No change to exterior size: residence 1 com'l 0 Other work(describe Check Occupancyllnformation 1"Floor 2° Floor Other floor -Tot2iii Below sq.ft. sq.ft, sq.ft. Square Feet Single family dwelling u Two family dwelling U Townhouse D Multifamily dwelling #of units U Office u Mercantile 0 Manufacturing U 1 car detached garage U 2 car detached garage Ll 3 car detached garage URY 0 1 car attached garage flu VVIX, QF_ �Q CC C3 2 car attached garage ,xr 3 car attached garage C3 Storage building- commercial 0 Storage building- residential U Other What is the proposed height of the structure feet Inches Will any second-hand or ungraded lumber be used? If so,far what? 1UQ Type of Heating System: electric/ oil /(ga.3 wood. /forced hot air I baseboard other: c,UA_f yL AJ I_r4 Number of Fireplaces to be installed 2 Number of.Woodstoves to-be installed List below the person(s)responsible for supervision of work as regards to building codes: Name Address Phone Number Builder /,&�_ e -3 —/�7�s L 4 KC- SZz,<f Plumber L A-ta R4,hwzv U/— '7 95;—' 9J917 Mason e_I,,1;6 � Electrician WAt&-, ioekle,%j Declaration please sign below after you have carefully read the statement: To the best of my knowledge 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 noted,and that such work is authorized by the owner. Further,it is understood that Uwe shall submit,prior to a Certificate of Occupancy or Certificate of Compliance being issued,as requested by the Zoning Administrator or Director of Building and Codes,an As Built Survey by a licensed surveyor;drawn to scale,showing actual location of all new constru. ti Signature: owner,owner's agent architecte�contr..t�. 7 Applicaticin for Permit—Septic Disposal System - Town of Queensbury 742 Bay Road Queensbury,NY 12804 (518) 761-8256 1. OWNER INFORMATION: Office Use Location of installation: C es l%i f—� p File Permit No.c.12w, Tax Map No. Fee Paid - Owner?s Name: 1"CP y, f bA'i1 S i f"Li € Address: 4606--� 4A"J=, too 2. INSTALLER'S NAME PHONE NO. 3. RESIDENCE INFORMATION: (circle year of dwelling,indicate#bedroom(s) and multiply#of bedrooms with applicable gallons per bedroom to.equal total daily flow) Year of House No of Bedrooms x Computation = Total Daily Flow ' 1980 or older x 150 gal/bdrm = 1980—1991 x 130 gal/bdrm = a 199�1�presen x 110 gal/bdrm = Garbage Grinder Installed yes ✓/ no-, Spa or Whirlpool Installed yes_ / no 4. PARCEL INFORMATION: (circle applicable information&indicate measurements) Topography Soil Nature Ground Water Bedrock or Impervious Material Domestic Water Suvply Flat sand at what depth at what depth mumcipal _feet we o m 'r' feet f - i well;water supply Steep slope clay _%slope other from any septic-system depth: absorption is>other i Percolation Test: (To be completed by licensed professional engineer or architect) { Rate: minute per inch (1III SYSTEM: For New Construction: All individual sewage disposal systems must be designed by a l ceased 5. FROPOSED SYS professional engineer or.architect(unless installed in a Planning Board approved subdivision). Add 250 gallons to the size of the septic tank and leach field for each Garbage Grinder,Spa or Whirlpool Tub. Septic Tank: /a 5'ri gallon (min. size 1,000 gal.) Tile Field: each trench_ 60 ft. Total System Length: Seepage Pit(s): - number of size ofeach: `-- by "^ Size'of Stone to be used:. # I depth or thickness feet Bed System Size: --'— x Alternative System: length and/or size 6. HOLDING TANK SYSTEM: (if required) Number of tanks: ' / Size of each: gallons /TOTAL Capacity: � gallons Note: Alarm System and associated electrical work must be inspected by a Town approved 'III electrical inspection agency. 7. SIGNATURE &INFORMATION FOR RESPONSIBLE PERSON(please read) For your protection,please note that pursuant to Section 136-29 of the Code of the Town of Queensbury,any permit or approval granted-which is based upon or is granted in reliance upon any material misrepresentation or failure to make a material fact or circumstance known by or on behalf of an applicant,shall be void. I have read the regulations with respect to this application and agree to abide by these and all requirements ofthe Town of Queensbury Sanitary Sewage Disposal Ordinance. l Signature of responsible person Date TOWN OF QUEENSBURY Richard A.Missita HIGHWAY Highway Superintendent DE' VAR MENT rrr Home(518)79&5127 742 Bay Road'- Queeinsbury,NY 12804 Michael F.Travis e• Deputy Highway Superintendent Off t'te Fha n , (518) 764-8211 (518)798-0413 Fax: (598) 745-4466 DRIVEWAY PERMIT DATE: ���7 L APPLICANT NAME: CO MI//, .6A)St TELEPHONE NO.: ADDRESS TO BE INSPECTED: t�h�S/euG� +�Ic !I)�� r°' I kV bA" RETURN ADDRESS: 17Aeov ' Sf Applicant must show exact location and width of driveway(s)to be connected to the highway by placing stakes at the specified location. The Superintendent of Highways of the Town of Queensbury has reviewed this application. The following action has been taken: STEP l: ( )Preliminary Approval NEED: ( }Slight swale ( )Level with the road , ( }Deep swale Size pipe to be used(if necessary) { )I2" ( )15" ( )I$" ( )24" ( )36" Preliminary-inspection completed by DATE Approval by Highway Supt. Deputy Supt Upon completion,please resubmit this approved permit for a final approval. STEP 2: ( }Final Approval ( )Rejected DATE: Richard A. Missita,Highway Superintendent ENERGY CODE COMPLIANCE APPLICATION TOWN OF QUEENSBURY, WARREN COUNTY 9000 HEATING DEGREE DAYS. Compliance Methods: PART 5 - Acceptable Practice Method 1&2 Family Dwellings (only) ,er, PART 6* - Thermal Rating - Component Trade Offs 1&2 Family Dwellings; Multi-Family Dwellings (3 stories or less) PART 4* - Design by Component Performance Commercial Buildings-Hi Rise Residential *Requires submission of worksheets APPLICANT'S NAME: PROPERTY LOCATION: t-SY-4jut 919S.P /4. .............. PART 5 METHOD OF COMPLIANCE BY ACCEPTABLE PRACTICE: 1 . Gross Floor Area - _s square feet 2 . Type of Heat - Electric Oil t.el, Gas Other 3 . Is building mechanically cooled? v< Yes No 4 . Percentage of area of windows and doors Over 17% 4ZUnder 17% 5 . R-VALUES FOR -INSULATION GIVEN BELOW MUST CORRESPOND TO R-VALUES AS SHOWN ON PLANS SUBMITTED: a. Roof R b . Exterior walls R C. Glazed areas R _�- ;L d. Exterior do6rs R - /6 e . Floors over unheated spaces R f . Edge of slab on grade (heated 'building) 2. R g. Basement/cellar walls (above grade) R f 3 /9 h. Basement/cellar walls (below grade) R 13 i . Heating/cooling-ducts-piping in unheated space R 6 . Service (domestic) hot water heating device Conforms to. minimum efficiency per code Yes No TEMPERATURE CONTROL MAXIMUM SETTING 1400 WILL NOT BE EXCEEDED Appj" =t' s9 �ure Date Phone Number I -Y' INSPECTOR' S REMARKS : V­N Fire Marshal's Office Town of Queensbury,742 Bay Road,Queensbury,NY (518)761-8205 Application for Fuel Burning Appliances & Chimneys applicable to solid fuel & vented-gas appliances Date-Y 7 20 6,?- Permit No. Application is hereby made to the Building&Codes Of cc the issuance of Building and Use Permit pursuant to the New York State.F-ire Prevention and Bitilding,Code. T lie applicant orowner agrees to comply with all applicable laws, ordinances, regulations, and all conditions that are part of these requirements and also will allow,all inspectors to enter premises to perform required inspections. NOTE to applicant: Rough-in and Final Inspections are required. Applicant Information Fuel Burning Appliance Information (circle appropriate words) Name: /A. Stove: wood coal pellet gas I:i r.p,La eQJu se r I- rFi c�ry-buffl , wood 0a 5 Address: :S1- 0 Fireplace, masonry: wood gas Furnace: wood gas oil Phone: If non-masonary applicance, please provide Manufacturer Name: Y, 6/r) Owner: c ~ AtO Model Number: (( 0(7) L,11 Address: i( P4 Chimney Information Phone: (circle appropriate words) g Vq Masonry block brick stone Flue tile steel size: inches Exact Address: i� 1 i` Pi of construction or tnstail'ation Factory-Built Manufacturer name: 1j,C_ Model Number: Note: Listed By: Number: Construction lInstallation must confonn to NYS Fire Prevention &Building Indicate(circle) chimney material: Code. Consult available Town of Queensbui)) Handouts regarding. required inspections. Double i.vall l Triple wall Insulated Direct venting Chimney Liner Fire Marshal Code# $Collected $Refunded Received from (refunded to): t 5 00, address: A 173 3389 (190) Public Safety A 233 2655 (230)Minor Sales DATE: White(Applicant) Green(Fire Marshal) Yellow(Bldg. Dept.) i Pink&Goldenrod(Cashier's Dept.) TOWN O F Q U E E N S B U RY BU TL,D S NG & CODE ENFORCEMENT 742 BAY RCA D QUEENSSLJRY NY 12804 �S! 8) 761-8256 ARRIVE : DEPART" = TNSP « ��--- g`xmsr►a. xaaScx+ ItF:Pc+*tn? cc�rar�xErccxx��. ------ autcr�.�xaP�.� �c+w�x..x.xxac� rnc3tol, apt_ cvmpl�.x) DATE SNSPECT2C3N REQUEST E2.ECESVEp : NAME _ P E RM S T • TYPE L�F STRUCTURE F O OT T NG S B AC K F S L L F RAM T N G P LCIMB T NG TNSUL73TTt�N YES Pdc7 CFiZMNEY/ '• 8 •, VEN'�'. fiETGliT E'LUMBTNG VENT.J'FTXTURES Rc3f3�'S NG . EX"S'ERTc3R FSNTSH HEATS.NG Hc3T WATER ME:L T E F VALVE S FLOORS F O UN DAT T CaN T N S U LA T T ON TNTERSt3R STASRS RAILINGS STOCKR�70M ENCL©SURE _ F—T R E 1 D E M T S E WALLS P E N S TRA T T O N FIRE DAMPERS +CETI..TNG �'TRE STOPPING FIRE DOOR�CLOSERS E.X.T'I.' DOOR �IARL:? ARaE E X S T S TA T R S J RA T L S - PLATFGIRMlELEVATOR - �1 HAN D T CA P P E D ACCESS � t r MA D S CAP P E D BATHS i H AIV D S CAP P E D P ARK S NG ` F T NAL E L E CTR S CAL S S T E PLAN VA R T AN C E R E `� F=NAL SURVEY PLAT FLAN TF RE OK TO ISSUE C C? OR C C __ MAP REFERENCE: MAP OF A SURVEY MADE FOR THE WEBSTER FARM DATED JULY 12, 1991 LAST REVISED AUGUST 26, 1991 BY VAN DUSEN & STEVES LAND SURVEYORS LANDS N/F OF MAINE LANDS N/F OF HILLER LANDS N/F OF WEBS I ER o -00 --- _ S,6 5 49 "f �\ 22_07 }o ;� AREA --_ iN co 905,169 sq.ft. _1 2 20.78 acres 20 SfTBa`K 0 o to o P' 2189.03' ~— --- N82 51 4-yy -~----_ 20' SETBACK LANDS N/F OF JENKIN IRF ®� �pp�ga7c .B. N4 2 3 Cv o t + N 7D 1�. x 11 CQ .� 0 w4 0 a � z (� z ;3 � v oQ� A v� z v> 0 a 1* r '3 m m � GRAPHIC SCALE 100 0 50 100 200 400 S ( IN FEET ) 1 inch — 100 tit~ SHEET 1 OF 1 DWG. NO. 1� RESIDENTIAL,FINAL INSPECTION REPORT Office No.(518)761-8256 Date inspection request received: Building&Code Enforcement $ Dept,of Community Development Arrive am/pm Depart �Ml Town of Queensbury Inspector's Initials 742 Bay Road Queensbury,New York'12804 NAME PERMIT# LOCATION DATE ,� -.2 4 C� TYPE OF STRUCTURE � - N/A YES NO COM1VENTS Chimney Height/"B"Vent/Direct Vent Location Fresh Air Intake Plumb Vent through roof Roof Complete Exterior Finish Complete Interior/Exterior Railings 30"to 36" Exterior Handrails,balconies,landing 18 in.or more Interior Handrails stairs both sides 3 or more risers Grade 2%away from foundation 8"clearance to sill plate Gas Valve shut-off exposedlregulator IS"above grade Gas Furnace shut-off within 30 feet or within line of site Oil Furnace shut-off at entrance to furnace area Furnace/Hot Water Heater operating Relief Valve(s)installed Headroom,6 ft.6 in.on stairs Basement stairs,6 ft.4 in. Handrail exterior stairs both sides more than 3 risers Interior privacy/trim/doors/main entrance 36" Floor Finish Bathroom/Kitchen watertight Interior Handrails Balconies/Landing 18 in.or more ailing across window in stairwell , t L- ' S s 12T. �� r l �moke Detectors: 1 every level every bedroom outside every bedroom inter connected Bathroom fans Plumbing fixtures Foundation insulation 3/4 hour fire door/door closer Garage fireproofing Garage penetrations sealed _ Furnace;in separate room protected(in garage) Light ventilation per room Safety glazing 18"or less from floor Electrical r Plan/Variance requiredjn Survey Plot Plan /vL �J �dv As Built Septic System layout required Okay to issue C/C(Certif.of Compliance) Okay to issue temp.C/O(Certif.of Occupancy) Okay to issue permanent C/O(Certif:of Occupancy) 12/19/2002 11:29 518-272-7724 HART ALARMS PAGE 02 3 ALARJ. N.Y.S. LHARTSYSTE (518)272-2007. 514 FOURTH STREET,WATERVLIET,NY 12189 INC. LIC.NO. 72000111377 December 18,2002 C r-p ` 2002 Mr.'Dave Hatin OW �0 Q':5EENt BURY ZI.ij P'4iNO w 1ai�i ODE Town of Queensbury Building Department Mr. Hatin: On November 20,2002 we completed the installation of a burglar&fire alarm system at the Smith Residence,275 Chestnut Ridge Road,Queensbury,New York 12804. On December 16,2002 we connected for digital monitoring. All devices,were found to be in working order. If you have any questions,please do not hesitate to call. Sincer ,. .� Steven M.Hart SMH/dmz WWW.HARTALARM.COM Town of Queensbury Fire Marshal's Office f i 742 Bay Road � t'Cv ��-''' Queensbury, NY 12804 Phone (518)761-8205 Fax(518) 745-4437 Fire Marshals inspection Report Request SCHEDULE Received: Permit#_ (�Z ��Z INSPECTION ON: Name: s��`�� aC)D AIUI DPMANYTIME Location: Is— ckjt APPROVED N/A YES NO COMMENTS EXITS AISLE WIDTHS r~ l p l EXIT SIGNS-NORMAL G - BATTERY EMERGENCY LIGHTING F FIRERE EXTINGUISHERS FIRE ALARM SY,$TEM l FIRE SPRINKLE SYSTEM/ L FIRE SUPPRESS N SY EM !/��9GYl� �� CI bove � I C�?LLi ✓�q HOOD INSTALLATI INTERIOR FINISHESu � , //- J STORAGE COMPRESSED @A§ CLEARANCE TO OPRINKNERS Arr(avc U -' CLEARANCE TO SATIN UNITS CLEARANCE Ig ELECTRIC L / �Z�j C��L{fit 0K REQUIRED SIG AGE EMERGENCY PLAN MAXIMUM OCCUPANCY SIGN CHIMNEY MASONRY ROUGH IN CHIMNEY FINAL -- �Jdle�f �7C 11 7 ROFACTORY BUILT ROUGHIN FINAL _ � �'vly 6t �' I�` U t V STOVE ROUGH IN bA79, 5kef 01 FINAL ,��� VENTED GAS f,�r fi11�2 jP� ©P�-���rbn APPLIANCE ROUGH IN FINAL FIREPLACE tUTASONRY ROUGH IN OK THIS) DATE OK FOR CO NOT OK FINAL FIREPLACE FACTORY BUILT ROUGH IN INSPECTED BY FINAL CONEDEV/CHRISJ/NIORDILETTERS20011FIREMARS HALINSPECTIONREPORT11022001 WHITE-BUILDING DEPARTMENT COPY _ YELLOW-OCCUPANT COPY �� 00 RESIDENTIAL FINAL INSPECTION REPORT Office No.(518)761-8256 Date inspection request received: Building&Code Enforcement Dept of Community Development Arrive am/pin Depairt Town of Queensbury Inspector's initials 742 Bay Road Queensbury,New York,12904 r'7 1 . Is ffy, 0 NAME �d PERMIT# LOCATION -76- CAe-�.-j-NJ(Yr Otae- DATE TYPE OF STRUCTURE SIC- N/A YES NO COMMENTS Chimney HeighbPB"Vent/Direct Vent Location Fresh Air Intake Plumb Vent through roof VA Roof Complete Exterior Finish Complete X Interior/Exterior Railings 30"to 36" Exterior Handrails,balconies,landing 18 in.or more ve Interior Handrails stairs both sides 3 or more risers Grade 2%away from foundation 1/11 8-clearance to sill plate Gas Valve shut-off exposed/regulator 18"above grade Gas Furnace shut offwithin 30 feet or within line of site. Oil Furnace shut-off at entrance to furnace area V Furnacefflot Water Heater operating Relief Valve(s)installed Headroom,6 ft.6 in.on stairs Basement stairs,6 ft.4 in. Handrail exterior stairs both sides more than 3 risers. Interior privacy/trim/doors/main entrance 36" floor Finish BatbroomMitchen watertight Interior Handrails BalconiestLanding 18 in.or more Railing across window in stairwells Smoke Detectors CG51te every level every bedroom outside every bedroom inter connected Bathroom fans Plumbing fixtures -4 Foundation insulation 3/4 hour fire door/door closer Garage fireproofing V Garage penetrations sealed Furnace in separate room protected(in garage)_ Light ventilation per ro V Safety glazing 18"or e s1 or I pp� Final Electrical Site Plan'/Variance requ ed Final Survey Plot Plan 12a)5(AA.� V As Built Septic System layout required. Okay to issue CIC(Certif.of Compliance) Okay to issue temp.C/O(Certif.of Occupancy)_ kay to issue permanent C/O(Certif.of= -n—cy)_—r i i � • � COMMONWEALTH ELECTRICAL INSPECTION SERVICE, INCs Main Office 176 Doe Run Road - Manheim, FA 1754 MUNICIPAL CERTIFICATE a ELECTRICAL APPROVAL Permit No #####i}#►iiflfflfff{{f##f1##fi#Y#IMM{#f Y i7 9 3 17 Cut-in Card No. 1/tt++ t►ulffflMH/tY lYYffs iti W41004 } 6046Y f1YYMM1YY111liff►fillfflf!!f{M!Y###YIMYYYYiiiu/{fi►f►//llffYMIMYY!}}frff}f►/f11 flffffitIYYMa fffaf I##Y1f L/n i i AAA# 1��7 l�oCatto+� Ali!#►MIffIH/1i#►iHllf##fuff###1Mifl##i#t#t#iiffM########/i#IMINIIY#INili##t##MNII{i####i###1#i#fflM#Ii#i#iMfff11f11fiii###########I#f##f##### ConsistiInstallah'onng of}if►f►►#####►###OfI Mae##i#####1####1 41 fi#M N#i###tiM#fflfffl#######} i11gM##/11#}}g1##t1iN►####/t�i#nf►l► ffff#}iiifu}f" I U A !j ■■,J■■J, M#Mi fff ##/tfi p !##fill i#M►##!{I##f►##1###flMooIof#i)i###/ffli##f►Milt###Np#ii 1p1####f##F{�####MM# Ni/.if)f11r lio!►f##1Nff f###►####f!##Iiiiifi##!!!###I.#q i 4flf lii!##{ft 1ff##iMlf#M►fflf!####�itiMM1##}!{1l11fH}}##1}I#H f##if##f losses##iNf#if###.##ffif!##ff//1p##Itii#i##iliff##IIH###1##}Y!}fi#IIf#/i}4i}f##1f####N1#1ii1lfffffff# �1Licei Installedo#YMMI►#1►it###1Ii i11f..M1lfff ff##Hf##fii# ##1 Y ffff##fff###It f##itl I I M{.M 1 ft###ffif#}iiff if a ' 1 }4fN/fffi{1t{{4ffflfiiipfif#fiffliff/ilififffflf The conditions following governed the issuance of this certificate, and any certificate previously issued is cancelled: f 1 ficate only covers the electrical equipment and installation conditions as of date} Upon the This certr y introduction of additional equipment or alterations, application shad be promptly rude for inspection, Inspectors of this Company shall have the privilege of m ' g inspections at any time, and if its rules are violated, the Company shall have the right o evok i certi catel r t Date,,,, #Mil!#fffffffl#ill#{I►fill/,,,,,,,#M#!##1 INSPECTOR iMMlfi#f{gffi0 MMIMiffIm*#f{i►##1##I Mae 1## ## p ## fI 11 #M#i if ofM i if#i##fffiff}f b#fl11 MpmhRr UPI.I.A.F.1. 0' 4? 4� 4J 0 Q) z U 4J w 'TJ 0 frr" V JA 1 y I \ 0) N z ixb w U I VI 4J (V V) c 4J ix Q I k,- , r 0 r1 0 R 4J s S. {!)u� , r { 0 U Q1 , CL 0 0 r-•' �t an RCS , 0 0 o m tea rJ r• Z I+ S { 3 � r H C 0 4,1'r � �) �Lv! Q ` � I 0 04J W Z4. 0 Q)t�. p"° 04'r d' C S., a)Z w .0 U W 0 0 0 0 0r-wRaiUC0 �� I � � � r" � Q0q- Rev 0 V) Rn D. .tl E"w ns Qa C c C? OIL 4J 4J 0 r-, 5+ 44 0 04 it(A QDS` 0 (Dw C � M 0' 0 ' 4WU )m PA UNU) Cr.C (00C4) 0 I a w 0 �r" (A ul4 N ox ". Qo0 0Ws. �� V) J Rw t. rr � 0 4- or^ 0 0 Vl r r v- VI � I� 0 0 4-w V1 e m G? 4a 4J -P t11 i y ' q.) r- o I% .P .0 4 0 Z I t'r � U.*0 S. 0 U 4J r• w ► D. NW NCL -0C IA QU0 :30. C6 'r- 0TJ # p, 0 0 0 0 Q?'r" >0 41 (D W 'r• Pbr 0 r 0.0 0 0 Q) 00 U S. r0 z J C a0,jU, LLI(nU 1%.,L, 7U V 0 NOV 06 2002 3: 36PM HP LASERJET 3200 - P. 1 NACE ENGINEERIN( ,' ' 169 Haviland Road,Queensbury,NY 12804 Phone-519-745-4400 Fax -518-792-8511 November 6,2002 Job#49095 Mr.Dave.' Hatin VIA FAX—745-443 7 Town of Queensbury 742 Bay Road Queensbury,NY 12804 RE: 'Septic System-Collette Construction Smith Residence,Chestnut Ridge Road Dear Dave: At the request of Mr.Ken Collette,I have performed a percolation test at the site of the house he is constructing' for Mr. Ed Smith on Chestnut Ridge Road in Queensbury. The test was performed approximately 15 feet south of the southern end of the constructed septic system. The results of the testing are as follows: Percolation test Stabilized percolation rate— I"in 6 minutes,35 seconds Thetest was run in the native silty loam soil at a depth of 20 inches in a 28 inch deep hole. The hole was presoaked with 6 gallons of water and the test was run 5 times until it stabilized with three consecutive runs at 6:05, 6:25 and 6:35 respectively. Please 61.1 me if you have any questions. Suic Thomas W.Nace,P.E. Fax copy:Ken Collette—668-3952 7z- -UOW OF QUEENS Y B IL ING_ --. E ORCEMEHT 742 "MCI Qu�ensbury _ 2�0� (518� 76I-8256 EPTIC DISPOSAL SYSTEM INSPECTION Name _ t Location SOIL TYPE Sand- Loa 1 ay- Resu1 is of Percol ati on Test- ( i -F applicable ) Rate-Minute/Inch TYPE OF SYSTEM: ABSORPTIOR FIELD : Total eng t-h tZ,�-Z) Length of each trench f - Depth of trenches Size of stone _ SEEPAGE PITS: N umbe r- Si-ze - -Ft _ X. -Ft _ Stone size PIPING: Size T�.Ype B 3 d g _ t o Tank- Tank- to Dist _ Box rr w Di s-t _ Box to Fi eZ d/P - s. Open1 n g s Seal ed ? Yes No Par-ti a1 L.00ATI /SEPARATIO1 Foundation to Tank > -Feet Foundation -to Rbsoi-pti on r� -Feet Separation o-F P i -ts eet Conforms as pet^ Plo-t Plan Yes Ito LOCATI OIL OF SYSTEM ON PROPER- _ ( ci rc1 e one) Front - Rear Left Sid - R-ight Side M-i dddl e F rcn -t COI +lE�i S e SYSTEM USE APPROVED v YES (F) A r-r-I v ed; D c--p a r--teja 24h Bui 7 �ii reg InSPectc�r - `'' •r 1 t ' Town of Queensbury Fire Marshal's Office 742 Bay Road Queensbury, NY 12804 Phone (518)761-8205 Fax(518) 745-4437 Fire Marshal's Inspection Report Request SCHEDULE Received: Permit# Ag INSPECTION ON: EANYTIME Name: ( 1%, � 1, o lk, � AM PM Location. dA AFP 10ED N/A YES NO COMMENTS EXITS AISLE WIDTHS EXIT SIGNS-NORMAL - BATTERY EMERGENCY LIGHTING FIRE EXTINGUISHE9@ FIRE ALARM SYSTEM FIRE SPRINKLER SYS EM FIRE SUPPRESSIONS TEM HOOD INSTALLATION X INTERIOR FINISHES '-I Q �� STORAGE COMPRESSED GAS CLEARANCE TO SPRINKLES Lj CLEARANCE TO HEATING 111 UNITS CLEARANCE TO ELECTRI AL REQUIRED SIGNAGE ` EMERGENCY PLAN �d MAXIMUM OCCUPANCY SIGN CHIMNEY MASONRY ROUGH IN FINAL ad - CHIMNEY FACTORY BUILT ROUGH INL1��)X1 V V7-, WOOD . FINAL STOVE ROUGH IN VENTED GAS FINAL APPLIANCE ROUGH IN l FINAL FIREPLACE MASONRY ROUGH IN OK THIS DAT Off( FOR CC ' N T OK FINAL FIREPLACE FACTORY BUILT ' ROUGH IN INSPECTEDY FINAL COMDEV/CHRISJMORD/LETTERS2001/FIREMARSHALINSPECTIONREPOR 11102200fYELLOU-OCCUPANT COPY WHITE-BUILDING DEPARTMENT COPY Office Use GENERAL INSPECTION REPOR rc::7\—� Inspector: Town of Queensbury Ready at time: Dept. of Community Development Request received: Meet: Building& Code Enforcement At time: 742 Bay Road Queensburj; NY 12804 ARRIVE a DEP R " a Notes: (518) 761-8256 Inspector's Initia - -d--�Pr NAME: PERMIT# c2w) LOCATION: C? A,0,1&t-rQ461 INSPECT ON(date): TYPE OF STRUCTURE: RECHECK N/A YES NO COMMENTS Footings/Piers Monolithic Pour Form Reinforcement in Place % The contractor is responsible for providing protection from freezing (3c) for 48 hours following the placement of the concrete. Materials for this purpose on site Foundation,(Wallpour Reinforcement in Place Foundation/Dampproofing Backfill Approval Plumbing Under Slab Plumbing Vent(Vents in Place ughPlumbing Rou�I bin! isuiatio ��ouandation Walls Interior R- 10 Foundation Walls Exterior R- Floors R- c-V--%L-k%�G Walls R- I Li Ceiling R- n!?2 Duct work or piping in unheated spaces R- Proper Vent,Attic Vent Framing Jack Studs/Headers Bracing/Bridging Joist Hangers Jack Posts/Main Beam Air Infiltration Barrier Fire Separation 1,2,3,hour Peetra'io n Sealed ire Wall2 ,/Firetopp n�L:\SueHemin.-way\Building.Codes.Inspection.FORMS\GENERAL INSPECTION REPORT.doc Office Use GENERAL WSPECTION REPORT Inspector: Town of Queensbury Ready at time:��_ Dept. of Community Development Request received: Meet: Building& Code Enforcement At time: 742 Bay Road Queensbury, NY 12804 ARRIVE . D ART% a Notes: (518) 761-8256 Inspector's Initial � , 4. cl NAME: r� PERMIT# LOCATION: , A�Tit36 INSPECT ON(date): cL� J TYPE OF STRUCTURE: RECHECK N/A YES NO COMMENTS Footings/Piers _ Monolithic Pour Form 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/V�Tallpour ti j �(�� t� � ?7 Reinforcement in l�l� Foundation/Dampproofmg Backfill Approval Plumbing Under Slab Plumbing Vent/Vents in Place Rough Plumbing Heating Rough-In Irsulation Foundation Walls Interior R- �� � 1r� Foundation Walls Exterior R- Floors R �� �d� Walls R- KN Ceiling R- Duct work or piping in a unheated spaces R- Proper Vent,Attic Vent , ` t r Framing �10Q�� � k 6�)b Jack Studs/Headers _ BracmgtBridgmg Joist Hangers Jack Posts/Main Beam Air Infiltration Barrier Fire Separation 1,2,3,hour Penetration Sealed Fire Wall 2,3,4 hour Firestopping L:\.SueHemingway\Building.Codes.Inspection.FORMS\GENERAL INSPECTION REPORT.doe Office Use GENERAL INSPECTION REPORT Inspector: Town of Queensbury I (Z), Ready at time: Dept. of Community Development ment Request received: 0 Meet: Building& Code Enforcement At time: 742 Bay Road Queensbury, NY 12804 ARRIVE Ma T.�-1�� Notes: (518) 761-8256 Inspector's Initia NAE: S 11441., 0 1 M M1 rPERMIT# LOCATION: gi INSPECT ON(date): lo Z- c-7 4A TYPE OF STRUCTURE: GI- V'- RECHECK N/A YES NO COMMENTS Footings/Piers Monolithic Pour Form 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/Wallpour Reinforcement in Place Foundation/Dampproofmg_ Backfill Approval Plumbing Under Slab Plumbing Vent/Vents in Place Rough Plumbing-_ Heating Rough-In Insulation Foundation Walls Interior R- Foundation Walls Exterior R- Floors R- Walls R- Ceiling R- Duct work or piping in unheated spaces R- Proper Vent,Attic Vent /T.Framing A- b--) Jack Studs/Headers Bracing/Bridging- Joist Hangers Jack Posts/Main Beam Air Infiltration Barrier Fire Separation 1,2,3,hour Penetration Scaled Fire Wall 2,3,4 hour Firestopping_ L:\SueHemingway\Bttilding.Codes.Inspection.FORMS\GENERAL INSPECTION REPORT.doc Office Use GENERAL INSPECTION REPORT Inspector: Town of Queensbury Ready at time: Dept. of Community Development Request received: Meet: Building& Code Enforcement At time: 742 Bay Road Queensbury, AT 12804 ARRIVE a Notes: a Y7L-pSamld��m EP (518)' 761-8256 Inspector's Initial, NAME: PERMIT# LOCATION: a es ZinjiZr If, �2 te INSPECT ON(date TYPE OF STRUCTURE. RECHECK L/ N/A YES NO COMMENTS Footings/Piers Monolithic Pour Form 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 FoundationAYallpour Reinforcement in Place Foundation/Dampproofing_ Backfill Approval Plumbing Under Slab Plumbing Vent/Vents in Place Rough Plumbing__ Heating Rough-In._ Insulation Foundation Walls Interior R- Foundation Walls Exterior R- Floors R- Walls R- Ceiling R- Duct work or piping in unheated spaces R- Proper Vent,Attic Vent jXT- ramin el-0 Jack Studs/Headers V Bracing/Bridging Joist Hangers Jack Posts/Main Beam Air Infiltration Barrier Fire Separation 1,2, 3,hour 17L- Penetration Sealed Fire Wall 2,3,4 hour Firestopping_ L:\SueHemiiigway\Btiilding.Codes.Inspection,FORMS\GENERAL INSPECTION REPORT.doe cgl�fftce Use GENERAL INSPECTION TORT 3 Inspector: Ready at time: VON, Town of Queensbttry Dept. of Community Development Request received. V Meet: Building& Code Enforcement At time: 742 Bay Road Queensbury, STY 12804 14RRIVEL7, -- � ; am m otes: (518) 761-8256 Inspector's InitiNAME: T# Z Q 0 Z- Z 7Z LOCATION: y l INSPECT ON(date): Y //o Z lVOvri 714A�- TYPE OF STRUCTURE: RECHECK NIA YES NO COMMENTS Footings/Piers ,� 1(� Monolithic Pour Form. Reinforcement in Place Z �) The contractor is responsible for M �(-- providing protection from freezing for 48 hours following the placement 61�C—CLy(Z- l�W � of the concrete. r[ Materials for this purpose on site FoundationlWallpour Reinforcement in Place _ Foundation/Dampproofmg l Backfill Approval Numbing Under Slab ,v Plumbing VentlVents in Place , .�Rough Plumbing Heating Rough-In Insulation Foundation Walls Interior R- Foundation Walls Exterior R- ~� Floors R Walls R- Ceiling R- Duct work or piping in unheated spaces R- r Vent,A 'c Vent F5a'ck n 1, StudslHeaders ',Bracing/Bridging 'Joist Hangers Jack Posts/Main Beam" Air Infiltration Barrier F' e Separation 1,2,3,hour enetration Sealed Fire Wall 2,3,4 hour Firestopp V ��� �� ✓ L:LSueHemingwaylBuilding.Codes.Inspection.FORMS\GENERAL INSPECTION REPORT.doc Town of Queensbury Fire Marshal's Office 742 Bay Road Queensbury, NY 12804 Phone (518) 761-8205 Fax(518) 745-4437 Fire Marshal's Inspection Report Request SCHEDULE Received: PjDrmij INSPECTION ON Name: AM PM ANYTIME Location: 0 APPROVED N/A YES NO COMMENTS EXITS AISLE WIDTHS EXIT SIGNS-NORMAL - BATTERY EMERGENCY LIGHTING FIRE EXTINGUISHERS FIRE ALARM SYSTEM FIRE SPRINKLER SYSTEM FIRE SUPPRESSION SYSTEM HOOD INSTALLATION INTERIOR FINISHES STORAGE COMPRESSED GAS CLEARANCE TO SPRINKLERS CLEARANCE TO HEATING UNITS CLEARANCE TO ELECTRICAL REQUIRED SIGNAGE EMERGENCY PLAN MAXIMUM OCCUPANCY SIGN 0K CHIMNEY MASONRY ROUGH IN FINAL FA, I op 01a CHIMNEY AFACTORY BUILT ROUGH IN c,� K WOOD F.INAL STOVE ROUGH IN FINAL VENTED GAS APPLIANCE ROUGH IN FINAL FIREPLACE MASONRY ROUGH IN /aQ-- fs5- 01I TI-If S D 0 K FO -C O - . OT OK FINAL FIREPLACE V-6 FACTORY BUILT ROUGH IN INSPECTS y FINAL COMDEV/CHPJSJMORDILETTER$2001/FIREMARSHALINSPECTIONREpoRT11022 I WHITE-BUILDING DEPARTMENT COPY YELLOW-OCCUPANT COPY Town of Queensbury Fire Marshal's Office 742 Bay Road Queensbury, NY 12804 Phone (518)761-8205 Fax(518) 745-4437 Fire Marshal's Inspection Report Request I SCHEDULE Received: Perm )it# oilk INSPECTION ON: CO— Name- 'AM PM ANYTIME ANYTIME Location: APPROVED N to YES NO COMMENTS EXITS AISLE WIDTHS 57C EXIT SIGNS-NORMAL - BATTERY EMERGENCY LIGHTING FIRE EXTINGUISHERS FIRE ALARM SYSTEM FIRE SPRINKLER.SYSTEM FIRE SUPPRESSION SYSTEM HOOD INSTALLATION INTERIOR FINISHES STORAGE COMPRESSED GAS d*, CLEARANCE TO SPRINKLERS CLEARANCE TO HEATING UNITS CLEARACE TO ELE REQUIREDN SIGNAGECTRICAL 10( VALeJV EMERGENCY PLAN MAXIMUM OCCUPANCY SIGN bc7 c U G�l` `�-�� U G CHIMNEY MASONRY ROUGH IN CHIMNEY FINAL FACTORY BUILT ROUGH IN �- �� FINAL WOOD STOVE ROUGHIN FINAL C/ VENTED GAS APPLIANCE ROUGH IN FINAL FIREPLACE MASONRY ROUGH IN OK THIS DATE OK FOID, CO NOT OK FINAL FIREPLACE . FACTORY BUILT ROUGH IN �ITPEECTED BY FINAL V ........... COMDEV/CHRISJNWORDILETTERS200WIREMARSHALINSPECTIONREPORTiIO22001 WHITE-BUILDING DEPARTMENT COPY YELLOW-OCCUPANT COPY Office Ilse Use GENERAL INSPECTION REPORT Inspector: Town of Queensbury Ready at time: Dept. of Community DevelOp7nent Request received: 5;/Ao/o Meet: Building& Code Enforcement At time: 742 Bay Roadt Notes: Queensbury, NY 12804 ARRIVE amlpm: DEPARTt am/pm (518) 761-8256 Inspector's Initials NAME: PERMIT# 7 00 LOCATION: INSPECT ON(date): TYPE OF STRUCTURE: RECHECK N/A YE NO/ COMMENTS �ootings/Piers Monolithic Pour Form Reinforcement in Place V 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/Wallpour Reinforcement in Place Foundation/Dainpproofmg Backfill Approval Plumbing Under Slab Plumbing Vent/Vents in Place Rough Plumbing Heating Rough-In_ Insulation Foundation Walls Interior R- Foundation Walls Exterior R­ Floors R- Walls R- Ceiling R- Duct work or piping in unheated spaces R- Proper Vent,Attic Vent Framing Jack Studs/Headers Bracing/Bridgmig- Joist Hangers Jack Posts/Main Beam Air Infiltration Barrier Fire Separation 1,2, 3,hour Penetration Sealed Fire Wall 2,3,4 hour Firestopping_ L:\SueHemingway\Biiilding.Codes.Inspection.FORMS\GENERAT,INSPECTION REPORT.doc Ofce Use GENERAL INSPECTION REPORT Inspector: Town of Queensbury Ready at time: Dept. of Community Development Request received: �Zi1 0 Meet: Building& Code Enforcement At time: 742 Bay Road Queensbury, NY 12804 ARRIVE am "'am/pm: DEPAR am/pm Notes: (518) 761-8256 Inspector's Initials NAME: PERMIT# o 04,) —c2 LOCATION: ('.. —e Sfi N t INSPECT ON(date}; TYPE OF STRUCTURE: RECHECK NIA YES NO COMMENTS Footings/Piers Monolithic Pour Form 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 FoundationANTallpour Reinforcement in Place_ Foundation/Dampproofmg #'-Backfill Approval Plumbing Under Slab Plumbing Vent/Vents in Place Rough Plumbing Heating Rough-In Insulation Foundation Walls Interior R- Foundation Walls Exterior R- Floors R Walls R- Ceiling R- Duct work or piping in unheated spaces R- Proper Vent,Attic Vent Framing Jack Studs/Headers Bracing/Bridging Joist Hangers Jack Posts/Main Beam Air Infiltration Barrier Fire Separation 1,2, 3,hour Penetration Sealed Fire Wall 2,3,4 hour Firestopping L:iSueHemingway\Building.Codes.Inspection.FORMSIGENERAI,INSPECTION REPORT.doc Office Use GENERAL INSPECTION REPORT - Inspector: Town ofQueensbu Ready at time: A � Dept. of Community Development Request received:�G�- Meet: Building& Code Enforcement At time: 742 Bay Road Queensbury, NY 12804 ARRIVE 10 a D ART �m Notes: (518) 761-8256 Inspector's Initia NAIVIE: M t t t"C PERMIT# LOCATION: ' 'ii ` N 01 Pe INSPECT ON(date): I,_/o . TYPE OF STRUCTURE: RECHECK N/A YES NO COMMENTS Footings/Piers Monolithic Pour Form 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/W allpour Reinforcement in Place oundation/D ampproofing ackfill Approval `!!! Plumbing Under Slab Plumbing Vent/Vents in Place Rough Plumbing Heating Rough-In Insulation 0.,br('Foundation Walls Interior R- .Foundation Walls Exterior R- Floors R Walls R Ceiling R- Duct work or piping in unheated spaces R- Proper Vent,Attic Vent Framing Jack Studs/Headers Bracing/Bridging Joist Hangers Jack Posts/Main Beam Air Infiltration Barrier Fire Separation 1,2,3,hour Penetration Sealed Fire Wall 2,3,4 hour Firestopping i L:\SueHemingway\Bttilding.Codes.Inspection.FORMSIGENERAL INSPECTIO REPORT.doc Office Use GENERAL INSPECTION REPORT Inspector: Town of Queensbury Ready at time: Dept. of Community Development Request received. Meet: Building& Code Enforcement At time: 742 Bay Road Queensbuij; AT 12804 ARRIVE Z-0 am/ Notes: (518) 761-8256 Inspector's Initia NAME: PERMIT# — Ism LOCATION: cLa C\ INSPECT ON(date): TYPE OF STRUCTURE: RECHECK,-,"' N/A YES,,NO COMMENTS Voti<ngs/Piers Monolithic Pour Form Reinforcement in Place Monolithic Po ur Reinforcement Pl ace la Farm ce trprotectionrisresponsibl f fr i� in The contractor is responsibl for providing from fr ezi from _lit for 48 hours following the pl ce ent c� of the concrete.or ispurpose 0 Materials for this purpose on Foundation/Wallpour Reinforcement in Place Foundation/Dampproofing Backfill Approval Plumbing Under Slab Plumbing Vent/Vents in Place Rough Plumbing Heating Rough-In Insulation Foundation Walls Interior R- Foundation Walls Exterior R- Floors R- Walls R- Ceiling R- Duct work or piping in unheated spaces R- Proper Vent,Attic Vent Framing Jack Studs/Headers Bracing/Bridgmig— Joist Hangers Jack Posts/Main Beam Air Infiltration Barrier Fire Separation 1,2,3,hour Penetration Sealed Fire Wall 2,3,4 hour Firestoppig— L:\SueHemingway\Building.Codes.Inspection.FORrvfS\GENERAL INSPECTION RkPORT.doc DON LOVELAND Inspector's Na. Flectzical Inspcctor Date 20 P.O.COX 703 "AGUE,NY 12336, (510)643-6724 COMMONWEALTH ELECTRICAL INSPECTION SERVICE INC. 1-800-562-9934 (Consulting and Fire Inspection Services) (incorporated in the states of Maryland,New York,Pennsylvania,Delaware and West Virginia) Desiring Certification 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. PLEASE PR,(NT Owner... ...........S...—...,... A..---,.............................................................................. Type Bldg. E DWG E Othe .. .. ... Occupant ....... ............................................................---..............................................--........... Building Permit Na. Job Location ...cA.r.s7-,v.vt.....C .....0:��..........................City . ................................... State ........ County ..WA/.�U. .V?-,V.............................Twp.........................--..........M/C#......................................... Swimming Pool—New El Old El ..........p...... L Directions to Job Site .......... ....... ........... ............ ............ ...... ...... ................................................. ................................. ......... ........ ..........I--.............--..........................--11......................... ....... ....... ......... ............ Application For Rough Wiring VFixtures O'Service .....--...........---............—1............I................................................—............ Work—New l? Additional 0 Bldg.—New 0 Old El Ready for Inspection ......................................................................... APPLICANT'S LICENSE# PERMIT 0 SIGNATURE PLEASE PHONE PRINT NAME APPLICANT'S`, PPLICANT'S _CV UA N ME OF TILITY ADDRESS j/ = - 1�;j Ip q,-OFFICE TO CITY STATE ZIP CODE _j BE NOTIFIED SPACE BELOW FOR USE OF INSPECTORS ONLY ROUGH WIRING AMP SERVICE OUTLETS EQUIPMENT PUMP SWITCHES HEAT OVEN PUMP SURFACE GARBAGE RECEPTACLES UNIT DISPOSAL UNIT MEDIUM BASE RANGE DISHWASHER FIXTURES MOGUL BASE WATER DRYER FIXTURES HEATER FLUORESCENT AIR AMP, RECEPTACLES FIXTURES CONDITIONER FRAC.H.P. MERCURY VAPOR OR WIRING&CONTROLS FOR BURNER QUARTZ FIXTURES --[715 20 25 3 VENT FANS H.P. MOTORS: 1120I 1112�11111 �1-1/21 2 1 3 5 171/2 0 40 50 1 75 100 MARK NUMBER OF EACH SIZE I I Inspector's Comments: OFFICE USE ONLY WORK INSPECTED OTIFIED REPOR- N cc TED FEE PAID 0 SERVICE'DATE 50N- TOTAL $ Date Received: - TRACTOR R.W.DATE OWNER CHECK NO. FINAL DATE OCCUPANT CHARGE Certificate No.: CERTIFICATE NEEDED AGENT CASH Date Sent: EIYES ODUP ELEC. LT.CO INSPECTOR Progress ❑ THIS APPLICATION EXPIRES ONE YEAR FROM DATE MAKE ALL FEES PAYABLE TO C.E.I.S.INC. WHITE/OFFICE PINMNSPECTOR YELLOW/OFFICER GOLD/CUSTOMER