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1987-921 4 1 1 CERTIFICATE OF OCCUPANCY TOWN OF QUEENSBURY WARREN COUNTY, NEW YORK Date .duly 7 1989 This is to certify that work requested to be done as shown by Permit No. 87-- 921 has been completed. This structure may be occupied as a o Two Family r Location 11 Queen Anne Court - Queen Victorla ' s Grant Owner Guyer Builders , Inc . f By Order Town Hoard F TOWN OF QUEENSBURY Building dr Zoning Inspector S f C r BUILDING PERMIT TOWN OF QUEENSBURY No. 87-921 � WARREN COUNTY, NEW YORK CD PERMISSION is hereby granted to Queen Victoria ' s Grant N OWNER of property located at 11 Queen Anne Court Street, Road or Ave. in the Town of Queensbury, To Construct or place a of Two Family Dwelling 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. Q C t. OWNER'S Address is Guyer Builders Inc . 119 Dunning St . C Ballston Spa , N . X . 12020 ,ry' r7 0 2_ CONTRACTOR or BUILDER 'S Name �3 Same m c., 3. CONTRACTOR or BUILDERS Address Same rt 4. ARCHITECT'S Name r 5. ARCHITECT'S Address m ro B. TYPE of Construction — (Please indicate by X) ro C'7 ( X) Wood Frame I I Masonry { I Steel { ) rt rt 7. PLANS and Specifications No. 34 ' x 43 ' as per plot plan , specifications and application including septic system and attached one car garage . MODEL L , t S, Proposed Use o of Two Family Dwelling "-h to a $5 . 00 C/O $ 75 . 00 PERMIT FEE PAID — THIS PERMIT EXPIRES July 1 , yg 88 w c (If a longer period is required an application for an extension must be made to the Building and Zoning inspector of the town of Queensbury before the expiration date.) Dated at the Town of Queensbury this 31st Day of December 19 87 SIGNED BY ,/ ': ?' for the Town of Queensbury Building and Zoning Inspector TO BE COMPLETED B PTO Application No . , .Jd�u# �7tsQc+n9a6eer Permit Issued 19 1U11 DSr1G and ZONING DEPARTMENT Permit Expires lg L. � 00 � Bay and Ha►riland Road, R,D. 1 Box 98 zoning Designation 0 00T 2 97 Queensbury, New York 12801 Variance No . Site Plan Review No . Approved by : /j Y c rL7 APPLICATION FOR � �� EU I LD I NG 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 : Guyer Builders , Inc . P . O. Address 119 Dunning Street Ballston. Spa , New York 1202(] Tel . ( 518) 899-9161 Property Location : #11 Queen Anne Court Tax Map No . 121 / 4 r+ 2 Street number or building lot number Subdivision name (if applicable) Queen Victoria ' s Grant THE PERSON RESPONSIBLE FOR SUPERVISION OF WORK AS REGARDS BUILDING CODES IS : Richard He Over III ( 518) 899-9161 Name P. O. Address _ Tel No . ,�_._...,.. Name of builder Grayer Builders , Inc -Address 119 Dunning Street Tel . ( 518 ) 899-9161 Nam of plumber Guyer BulIders , nc •Address 1119 ixunling Street wwwwwwwwwTel , Name of mason wwwwwwww �wwwyer ers , in g ree Tel . NATURE OF PROPOSED WORK : * ZONING INFORMATION • X`wwwWWwAwwConstruction 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 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 REQUIIREED PEEew . " 10 Size of property 100± pR anp3Lft}� X 120 ft . TL/ " Existing building ( s ) Size ft X�`ft . PROPOSED BUILDING ANDUSE : Model USE : .Existing building (s ) Use NIA Size of new struc:ture 34 ft X 43 ft Foundation-pier slab crawl/partial/full * Proposed building, distance from property line circle one ) * see ffbt plan Now of stories (habitable s,p}�ace) 1 * Front yard 30+ ft Rear yard 30+ ft Height ( grade to ridge ) 2i ' O ft . * Side yards 15+ ft and 15+ ft , If residential, no. of families of 2 * If on corner , setback from side street Scwft No . of rooms ( excluding baths ) ^ * OCCUPANCY INFORMATION - He* of bedrooms Noe of bathrooms * PRIMARY BUILDING - rimary heating system Baseboard a ectric* One family dwelling Thiswwwww, de° Feu in r pe of fuel Electricity �iTwa family dwelling Non of fireplaces to be installed * Multiple dwelling / Number of units Will a wood stove be installed? No * Permanent occupancy Central. Air conditioning? No * Transient occupancy * Business BUILDING STYLE, PRIMARY STRUCTURE * Industrial * Ranch Contemporary Lo cabin Other If addition, what will use be? Raised ranch Mansion Duple split level Old style Bungalow Cape Cod Cottage Other * ACCESSORY BUILDING ColonialRaw Town House " Detached garage/one car/ two car/ car ( CIRCLE ONE PLEASE ) * _X.Attached garage/one car/ two car/ One car * • * * • * * * * * * * * * * * * * Private storage building ESTIMATED MARKET VALUE OF * Other +CONSTRUCTION s 1 goo _ le IWORMATION ON , BUILDING SPECIE AT S , ON REVERSE SIDE OF THIS SHEET , TO BE COMPLETED ! Form SPA 4/8+6 mid-vl BUILDING PERMIT APPLICATION CONTINUED - BUILDING SPECIFICATIONS . Type of construction , wood frame , fire safe , etc . Wood frame Will any second-hand or ungraded lumber be used? if so , for what ? no Foundation wall material concrete block Thickness $"" Depth of foundation below grade (to bottom of footing ) 48" mirn, mum Will there be a cellar ? 'no Heated or unheated? Floor sqo footage sq ft Will there be a basement? na Will any portion be used as living space? ( If so , what port ` ? sq. ft . - - Type of use? Type of roof - sloped flat/shed/other Material of roof Fi rg ass s � ngles Size , wood studs '"X 6 spacing 24 "o . c . length 8 ft . exterior walls Joists ( floor beams ) lst . floor NIA !a_'"x ," spacing "o . c , span N/A ft . Joists ( floor beams) 2nd . floor +'x spacing �"o . c . span N A ft . Overlays (ceiling beams ) "x '" spacing 2�+ "o . c . span NIA ft . Roof rafters 2 "" X 1 'ea spacing g 4 o . c . span 12 ft . Roof trusses (pre-engineered) spacing �4 "o . c . span 43I ft . Exterior wall finish stained Of what material ? 5 / 8" x 4 ' x 8 ' texture Ill Interior wall finish pain s eetrock If a garage is to be attached , describe materials to be used for FIRE SEPARATION . 1 /2" type "X" sheetrock Is there to be an opening between garage and dwelling? yes If so will a Fire-rated door , enclosure , and self-closing device be provided? yes Will a flue-lined chimney be installed? No Height above roof N/A ft . Depth of chimney foundation below grade N A ft : Depth of fireplace hearth N A ft . in . Water supply - Municipal or private well municipal SEPTIC SYSTEM _ Distance from ANY private well ( including adjoining properties NTK ft . (A separate application is necessary for an repair or new installation of septic system) See S . P . E. D. S . permit # 02625255 Town of Queensbury R F F i D A 11 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 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, wihether ecifi d or not , and that such work is authorized by the owner . WZSy / SWORN TO BEFORE ME THIS Signature _ � _ _ _� er , owner ' s age cJ aired , contractor 1 day of PA-TRICIA F FURPHY rk Notary Puh[ic, State of New York Qualified in Schenectady Count Notary Public , , Noy , ' 4717048 i sion 'Expires 'Sept. 30, 19 It It ,fir SPECIAL CONDITIONS OF THE PERMIT . k By -------- ......-^------... -^-- TOWN OF QUEENSBURY 11L11 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 : is Gross floor area 936 S ' F " 2 . Type of heat Baseboard electric 3 . Is the building mechanically cooled ? No 4a percentage of area of windows and doors 15 . 9% A . Over 16 % Only wood is Uo value of gross area of walls , roof / ceiling and floors exposed to ambient conditions wwwwaftowl- 20 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 Be Under 16 % Only is R value of roof and floors exposed to ambient conditions. R-38 U =0 026 2 . R value of exterior walls )EKXXX R-23 . 5 Ua .0904+ 3 . R value of glazed area uw =0 . 20 4 . R value of doors R-14 . 9 5 . R value of floors over unheated spaces NIA 6 . R value of slab edge insulation no unheated slab N/A 7 . R value of slab insulation - heated slab 12 . 5 Be R value of heated basement/ cellar walls ( above grade ) NIA 90 R value of heated basement/cellar walls ( below grade ) N/A ld . Type of insulation Fiberglass C . Controls 1 . Thermostat maximum heat setting D . Duct Systems N/A 1 . 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 N/A i . Size of hot water or cooling carrying agent pipe 2 . R value of pipe insulation Fs Service Water Heating 1 . Performance efficiency N/A 2 . Temperature control setting maximum G . For Swimming Pool Only 1 . Maximum heating N/A Telephone Now. ( 518) 899-9161 ( applicant ' s s ure ) "` s APPLICATION FOR SEPTIC DISPOSAL. PERMIT Ref : S . P. E. D. S . DATE October el / 87 permit # New York - 0202525 MODEL L of E/L OWN LOCATION OF PROPERTY FOR INSTALLATION 11 Queen Anne Court Owner's Name: Guyer Builders , Inc . Telephone: ( 518) 899-9161 Address; _ 119 Dunning Street , Ballston Spa , New York 12020 Installer's Name: Guyer Builders , Inc Telephone: ( 518) 899-9161 2 A, C , E, 10 J, K, L, M Wumber of bedrooms (residential only) 2 3 F , G, H - . ., Total daily flow (compute Q 150 Sal per bedroom) 300 Tcgwgpaphy: circle one: iat Rolling Steep Slope % of slope Soil Nature: circle one* (Sand Loam Clay Other / Depth. $ ' feet + Groused Waters At what depth? unknown 8 feet + Bedrock or Isaperviouis Materials At what depth? unknown. feet Percolation test: circle ones sot require required / ra#e min. inch. Domestic water ~y: circle one: Qiii cipal Well Other IF domestic water supply is a Well: Separation: Watersupply from Septic absorption N/A feet * PROPOSED SYSTEM; Septic Tank gal. (minimum size. 1,000 gal.) TILE FIELDS Each Trench N/A feet / Total system length N/A feet * SEEPAGE PIT(S): Number of / Size each feet by feet. * Size of stone to be used / Depth or Thickness feet +Is * � s r * rr • * * * s * s * a * � * s * # s * it s a► * +� ai aR # e s s * s I U P 0 R T A N T * See S . P. E.D. S. a«.P3ease...LIST NEW RQUIPYENT TO DR INSTALLED permit & attached map ' (over) Section 11 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 propoped .location of the gystem Z.) 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, We fields and/or drywells B. No system shall be cowered 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 $Z50.00. Co. 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. l ba►e read the regulations above and agree to abide by these and all, requirements of the Town of Queensbury Sanitary Sewage Disponal C kdinance. Signature of.responsible person: Date: Town of Queensbury Building and Code Department Bay at Haviland Road Queensbury, New York 12801 (518) 792-5832 C a= n I'IA at ► nun, nr, /d ATAIDAI SaVANITY A etrinn DI ArF Tn I ' TOWN OF QUEENSB"Rl 13UXLVXSG AND CODES DEPARTMENT a H,VXLAND ROADS DAY�UEENSBURY . NEW PORK 12SO� TELEPHONE ( 518 ) 792-5532 ITpII3G INS'PEC"mR' S npoRT INSPECTION RECEIVED. gEQUE FOR f NAME Syr jCAT-TON PERMIT # APPROVED DATE _ - �" YES NO FOOTING/PIERS'POUR FORMS MONOLI HXCJIDAMp-pROOF'ING_��� FOUNDA APPROVAL BACKFILL PLUMBING ROUGH FRAMXNG ELECTRICAL ROUGH-IN INSULATION= FOVNDAT'rON FLOORS WALLS �! CEILING NAL INSPECTION : \T�EXNA HEIGH7'��----- iii 111 CHIMNEY ROOFING SIDING gCHESIST'EPS_�' _---- EXTERNAL PO NCE 6 RAILS CLEARA BELIEF V VE____ ,,AIRS- �. FIXTURES/ PLUMBING TRIMIpRIVACY D RS INTERIOR FINISHED FLOORS GARAGE FIREPROOFING DOOR CLOSER (S ) SMOKE DETECTORS P CTION L ELECTRICAL INS ,lgUCxl(7N FINAL APPROVAL OF CO FINA E OF OCCUPANCY MUS BE EFORE A SIGNED CERTIFIC BUXLDING ,DEPARTMENT OJ35 AXNED FROM TH RE OCCUPIED -" THESE PREMISES REMARKS .* ( e) I ao '` fPr Its' eo 40 XNSPE TOR r/ MIDDLE DEPARTMEV�y,. v 1N8PECT PN AGENCY, INC, r` i '1 911f1 Hsddaa1tie Cl ;Collnpsrir" 1 }, DateMay 24 , Z 9 89 af.�gP f CflftE that the electrical equipment listed has been examined ands approved as being in accord with the National Electrical Code, applicable governmental , utility and Agenc, y 'iPojes. u G er Builders Inc e- Dwlin Owner: y L7CC"upaltlCy."" S >; C occupant. Single Family sSV Location: 11 Queen Anne CourL , Queensburyr '(Warren Co) ''ems carwicale coves l6e'aleelric6l'i uipme nt and in star I a l ion Ins pec led this date. If additional equipment!should be introduced or aHerahona made fa - existing system thin Certificate shall be null and void, and applhcalion for 78 Outlets ' 48 Receptacles ; 15 Fixtures , : nspectionshouldbenubmi fled prem`ph fil ytolnisAgancy- EQUfpBnt: r ' Holder of this cartificale should present creme to his property insurance carrier 150 Amp Service ; 7 Appliances (agent or company)a a evl dunce ot�te rt lficat io n of electrical eq ui p mart approved as specified. .. y�rr :. �Se Guyer Iiui Zders : Znc ^� Rpptfcant: 119 Dunning Street p , 15 - 022616 Ballston Spa , DIY 12020 .�.. Form No. 703 EL 1.1117 Tawnr o� QUEENSBaRY BAY BUrZpxNG AND CQDES DEPAR ENT "AVrLAArD ROADS ELEPSBLTRY. NEW YQRH 2 28CJg- H(71VE (518) 7,92-.5832 &JILi)ING INSPECTOR ' S REPORT E'EQrJ'EST' FQR xNSPEC A,ME rxQ1y RECExVED PERMZ 2 F©[?T I APP"R+pVED hJC]1VDL HIC ERS YES .Vo POUNDATrON/D POUR `y'nRMS BACICFx,� OVA. ERG FING ROUGH PLUMHrIVAL FRAMxNG /�ECTRICAI HOUGH tf SArSUZ,TP QN: Il FQUNDDATZ QN WALZS CExLrNG FTNA r X VSP,EcTIQN: CH-mmy HErGHr ROOPTIVG sxD.,rNG L S2'AIRS-� ARCHES/S2'EPS PLUMDZ-1YCLEARANCE ;S RA-I rnrrRxraR FsxcTURE;s/RE�rF vALVE Fr,tir 'Rzna r,rzV,�cY Rs SHED PZOORS GARAGE PXRRPROoExNG DOOR CLQSER ( j sMcaxE DETECTbRS F.rlVAL ELEC?Rx�AL xNSPECTXOM L APPRQVA QF CQNSTRUCTZ pN A SxGNED CEIRTrF rCATE OF t?HTA xNEI7 FROM THE OCCUPANCY MUST HE THESE PREMx SES AR,v Occ rNG DEPART OC'CUPr 1vENT BEFORE ED! REMAKES; TOWN OF QUEENSBURY BUILDING AND CODES DEPARTMENT BAY & HAVILAND ROADS QUEENSBURY, NEW YORK 1280q. TELEPHONE (518) 792-5832 BUILDING INSPECTOR ' S REPORT REQUEST FOR INSPECTION RECEIVED S _/C� — NAME LOCATION ,I c}DATE - �) C- 4 PERMTT �#_ /`T / 2 )I -�--1 APPROVED YES NO FOOTING/PIERS MONOLITHIC POUR FORMS FOUNDATIONfDAMP-PROOFING BACKFILL APPROVAL +✓ROUGH .PLUMBING �RAMING ELECTRICAL ROUGH-Ilhi INSULATION: FOUNDA PION FL-OORS WALLS CEILING FINAL INSPECTION: CHIMNEY HEIGHT ; ROOFXNG SIDING EXTERNAL PORCHE (STEPS STAIRS-CLEARAN & RAILS PLUMBING FTXT ESjRELIEF VA,L[� INTERIOR TRIM PRIVACY DOORS FINISHED FLO RS GARAGE FIRE OOFING DOOR CLOSER S) SMOKE DE TEC RS FINAL ELECTR CAL INSPECTION FINAL APPROVAL OF CONSTRUCTION A SIGNED CERTIFICATE OF OCCUPANCY MUST BE OBTAINED FROM THE BUILDING DEPARTMENT BEFORE THESE PREMISES ARE OCCUPIED!' REMARKS: INSPECTOR .._.Down n/ �ueen � hure� 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 Backfill Framing Roofing Siding Masonry veneer Rough Plumbing Relief valves Ext . Porches Finished Floors Interior Trim i Stairs & Railings Cellar Drain Tile C concrete Floors {{ I'lbg . Fixtures Gar. . Fireproofing Door Closers Smoke Detectors chimney INSUT.ATION : Foundation Floors Walls Ceiling FINAL ELECTRICAL INSPECTION I)RIVEWAY APPROVA Final Building S r+vey Next scheduled inspection ( call when ready ) R��cnarks- Buil in Inspector 6/S6 and-vl �nuf.z v� �eteQ►Z .�6fur� BUILDING and ZONING DEPARTMENT Bay and Haviland Road, R. D. 1 Box 98 ©ueensbury, New York 12801 SEPTIC DISPOSAL ,SYSTEM INSPECTION NAME L.00AT I ON DATE ._ 4o�1691 PERMIT NO. SOIL TYPE - sand - Loam - Clay - PerColation Test Required? YES - NO Percolation rate - Min/Inch TYPE of SYSTEM.: Absorp tion ion field , total len h Length of a ch trench Depth of tre ches Size of grave SEEPAGE PxTS4 e o} Size- -.a _ft. _ t. Gravel size PIPING : size Type Bldg . to tank Tank to dist. x Dist . box to f eld f,. T"- Openings seal d? NO Partial LOCATION/s RATIONS - Foundation c tank ft. Foundation o absorpti n ft . Absorption to lot line ft. Separation f pits ft. LOCATION OF SYSTEM ON PR PERTY (circle one) Front - Rea - Left side - Right side COMMENTS : c SYSTEM USE APPROVED YES Bui Ins ector 01/86 and vl !0 Iq _../Dorn D�r �ueenshure� BUILDING and ZONING DEPARTMENT Bay and Havifand Road, R. Cr_ 1 Box 98 Queensbury, New York 12801 BUILDING INSPECTOR ' S REPORT NAME LOCATION r/,/' /�".[-.L-,��x..� (' •fir �,�✓/1 Date fA- / f _ Permit No . - Footing/Pier FForms 01 APPRovED YES NO Foundation waterproofing Backfill Framing Roofing Siding Masonry veneer Rough Plumbing Relief Va es Ext . Porc;!e Finished Flo rs Interior Trim Stairs & Railin s Cellar Drain Til Concrete Floors Plbg . Fixtures Gar . Fireproofing Door Closers Smoke Detectors Chimney 4/ NSULATION foundation rro Jr L, ' Floors Walls Ceiling FINAL ELECT CAL INSPECTION DRIVEWAY APP OVAL Final Builds Survey Next scheduled inspection ( call when ready ) Remarks- Fs i.ng Inspector 6/86 and-vl _7,e4tl►r of QMeCPJsf' ury BUILDING and ZOWNG Dr= PARTMLNT Bay and Haviland Road, R. D. t Box 98 Glueensbury, New York 12801 BUILDING INSPECTOR ' S REPORT NAME LOCATION — t ✓G % l,�,U� Date I �- 3 Permit to . I - ✓ = AP1 RUV�.D - yDS NC7 ly[ Footing/Pier Farms ff Foundation Water33roof ing Luck f.i 11 Framing Roofing Siding Masonry Veneer Rough Plumbing Relief Valves Ext . Porches -Finished Floors Interior Trim Stairs & Railings Cellar Drain Tile C.oilCretcC Vloors Plbg . Fixtures Gar . Fireproofing ❑ooy Closers Smoke Detectors Chimney INSUIi ATION Fcxunda t ion Floors Walla C- 'eiIinq FINAL k.LE TFzI AL INSF'ECTIOPI DRIVEWAY APPRC) Final Building, Survey _ Next ;sclleduled inspection ( call when ready ) Rema r ks- ui ldi ng I Ispe Lor f 186 mr3-vl BUILDING DEPT. COPY OF APPLICATION FORM 46-EL, NEW YORK BOARD OF FIRE UNDERWRITERS. FILE THIS COPY WITH BUILDING DEPT. WHEN REGUTAED. TEMP. s DqTE CITY OR VILLAGE Queemsb .Zry TOWNSHIP COUNTY waxxen STREET AND NO, OR ---- ROAD AND POLE NO. ._� , Ilmj",iat tY't, POLE N6 BETWEEN WHAT TWO CROSS STREETS IS PREMISES LOCATED? SECTION / ,1 BLOCK LOT OCCUPANT'S NAME HU14dING OCCUPANCY QWNER•S NAME ANDADDRESS U 7 q&9T a 11A S. lt TEL, * 161 8VPP1'IED . _ _ FROM THEIR i -- -' BUILDING r OFFICE DEFECTS IS NEW LJ OLD © T YYO'AK f—� IS NEW ADDITIONAL D 4 REMOVED l�1 LIST BELOW ALL EQUIPMENT WHICH YOU INSTALLER NUMBER OF OUTLETS No. of Fixtures a BRANCH Loon Lamp Receptacles MOTORS HEATERS CIRCUITS OFFICE USE ticn ONLY pllina Sills Attach't SWT Pendant Srrdcet No. T H'P' Warn A W.G.Wall Recap1s Type Each No. Each Na. A.W.G. INSPECTION Out- skis Sub- buss Basa- ment Iet FI. 2nd Pl. 3rd rL REMARKS: LIST OTHER ELECTRICAL DEVICES NOT SET FORTH ABOVE: 00 NOT USE THIS SPACE- This appl ice l ion is intended to cover the above-hated equipment to be inspect tad but if at time of ins you are authprized to make the inspection and adjust the lea to cover the additional ui peed an there b found additional equipment not abors hated, SIZE OF yy 1C� Pment, as provided by the applicant. MAINS N s FEEDERS ELECTRIC SIGN TOTAL LAMPS WATTS CHARACTER EXPOSED GAS TUBE SIGN OF WORK1=4401 In CONCEALED TRANSFORMERS OF VA WORK TO BE (NUMBER) CCAPACITYI STARTED COMPLETED SIZE OF SIGN SERVICE OVERHEAD UNDERGROUND MAKER ENTERS INWALDING I I OF SIGN INSPECTION REQUESTED ON OR NEAR AS WU1 � when NEW © O POSSIBLELE OLD AVOID DELAY BY GIVING FULL AND ACCURATE INFORMATION. ALL SPACES MUST BE FILLED IN OR APPLICATION MAY BE RETURNED. PRINT NAME AND ADDRESS NAME OF ''A's7;^r hadlexe �# DATE OF +��,p+�APPLICANT y s...�..� APPLICATION 10 i1 )8 Y STREET ADDRESS 1I9 Dwmd �tr Street TELEPHONE �' �161 CITY OR �e.�� POST OFFICE � '""a'e. My ZI 4� yyI} N LICENSE N FCABLE aG a� (REV. +Ia5) A SEPARATE APPLICATION MIDST BE FILER FOR EACH SEPARATE BUILDING REFERENCE DRAWINGS ANNE Ll ool 5A SITE UTILITIES SEPTIC 4 WATER Van DUSE N 4 STEVES SURVEY PLAN 1,3,5,7,9,11 QUEEN ANNE COURT PLOT PLAN 4 SEPTIC SYSTEM GUYER BUILDERS , INC . I GLV- 20 DWN ice! ►o- 2.97 1 Scale, 1 20'- 0