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1989-365 ,--. :, yrw :.�{,�„�,.,.{�„f _�.., '�'"F'' t .:' ,;.+` „a�"li3a `•«--sr+utr-YY+ 2' 5 ^a"c... .rs, y V \ j . 1 r CER.TIFICA'IE J QCCUFANCY f TOWN OF +QUEENSBURY WARREN COUNTY, NEW YORK Date WetoUer 4 19 This is to terrify that work requested to be clone as shown by Permit No. 89-365 has been completed. This structure may be occupied as a _Single Farm l y Dwelling ZAS Location -- � Ci � J g Owner Forest 'Hood Homes By C)rder Town Board TOWN OF QuserssSURY i i U t_ Director of Bldg, do Code Enforcement l BUILDING PERMIT TOWN OF QUEENSBURY No. WARREN COUNTY, NEW YORK tal I ta7 PERMISSION is hereby granted to OWNER of property located at 1 ctt 7 1 �.__gak Trpp ['irrlw Street, Road or Ave. in the Town of Queensbury, To Construct or place a Si 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. [3. CONTRACTOR NER'S Address is O XKSNX HC-o2 sox 286P �EfEi[i[ Warrensburg , N . Y . 12885 NTRACTOR or BUI LDER S Name O T7 lf Caa] or BUILDEWS Addressame 4. ARCHITECT'S Name i� i-+ W 5_ ARCHITECT'S Address Me rmi 6. TYPE of Construction — (Please indicate by X) XX) Wood Frame i 1 Masonry I I Steel I l r 1-n 7. PLAf4S and Speclficetions No. 26 ' x 69 ' two story Single family dwelling as per plot plan , d drifi ve cations , and application , including attached two car garage , septic and drive ay. , S. Proposed Use .s SINGLE FAMILY DWELLING Lr c r- C/o i ncl - 19 $9 $ oac nn PERMIT FEE PAID — THIS PERMIT EXPIRES De ember 1 -r (If a longer period is required an application for an extension must be made to the 8uiiding and Zoning inspector of the town of Ousensbury before the expiration date.l 1- Dated at the Town of Queensbury this 31ct Day of NaV i9 89 -- rr., SIGNED BY c for the Town of Queensbury L G B d ng and Zoni I nspector TOWN OF UEENS13URY APPI. ICATTON FOR BUILnrNG AND ZONING PERN1TT F. e c.G ev t�� ` TOWN:1-'�c-� Rev ' e EC'e ve VSBLIRy P1y ED Fee T'cu d S 5 AWAY 2 6 1989 WILDING AND CODES 1ai :1 'ARDTJ*oT Date. 1.e.4ued 0AY and UAVTLAND Rf7ADS--RD 1 Box 98 � 8LD(, g C©�� ��P7: g"7UE'EN58URY, NEIJ YORK 12804 PeAn),4t NO . s] `"l S��y�j ~ - Tel , ( 518 ) 792-58J.2 ExC 204 r * * r r ss r r * w r * r * * * w * w r w ■ * r x r w w r s ■ r ■ w s A PERMT MUST Ell OBTAINED BEFORE BEGINNING CONSTRUCTION . NO INSPECTIONS I ILL BE MADE UNTIL. APPLICANT HAS RECEIVED A VALID BUILDINC PERMIT . All applicable spaces on this application must be completed and the ti •intlature of the applicant must appear On the reverse side of this sheet . * 'A * * x * * * * * * k k * * * A; * * * * * A * * * * * * * * * x * * * * The owner of this property is : L l' . O . Address "FEY. . property location TAX MAP NO . Has there been any split of this property since October 1 , 1988 ? /, . • `" yes , Planning Board Review is necessary . Yes no 13DIVISION NAME , IF APPLICABLE LOT NCI • . rte person responsible for supervision of work as regards Building Codes is : HAKE P . D . ADDRESS `PEL . NO . . • tiame of builder Address Tel Name of Plumber �r F,ddress Tel Name of Mason Address Tel f ,lATuRE OF PROPOSCD 4,CRK : „ ZONING, INFORDIA'TION toffic ,e Lisa 0n1JJ ronscruccior, of a new building zONING DESIGNATICIN OF PROPERTY Addir ion to a LiuilJing # PERMITTED PRINCIPAL PERMITTED ACCESSORY -Altur:..Lion to a Luilding ( no clk:.uu}..: to excuriJr clilneni• iona ) * REVIEW REQUIRED - PLANNING BOARD TONING BOARD Utlsur work IJO: Cribb ) # SITE PLAN REVIEW M APPROVED DATE (.; ROSS ARLA OF PROIIOSLD� ! TT( UCTURE " VARIANCE # APPROVED HATE lst Floor -' } sq ft , f � r Remarks : 2 n d Floor r ` : ;r s q f t . COl tri l.L'j'rti INFORP%ATION J4LLQU I10ED 11E L1.Uti1 . :tier Floors sq t , 5114 f of prol'� rty f bU l! L x Pt . got cellar or basementl P'' LXjytlllxJ 17uilalii � ] ( :: ] Si �4 !.' l 7{ rt . TOTAL FLOOR AREA� � sq f t Lxi :.tit�g t3uil�lin�J ( 3 Uae Li44 oe new structure d ft X ft ' l'uui &d" cion-Icier/slaL/crawl/L]aartl"l/ fulI � ' Yrol3crsrd builLting , di:: cance fro+u propa.!rey line (circle one ) = Front yard ^_' Pt Rear yard r ft NJ . of .^,tories ( )talsat:.bl4 91hace ) ! ' Il..cight ( tjradu to ridgL : ) K ft . . Sidi: yardu � ti et and If ro :iduntlal , n0 . of families . if on eorn4r , :,;url "ck from side :icruuc rc Moo No . of room:; ( excluding bathal OCCUPANLY INFOI'MATICN + o . of b(.drooms ' PRIMARY LsUILDINU vow ) 0 of bathroom:; • * `OnQ Fanuly dwelling Itu:x ti[uJ �y :t uu� s�j�.: ssF fu41 ,. 2'►do f:,�uXily dw+slliny tio0 aa fire al3cu :: CO i,e irt: tall4: d ItMultiplo Alling / Number of units Nils. a L.+i? d SLOM41 L..: srt:: tSllud? r 1�@r1ltLinGrtt OCCULIALr1Cy Cunce"I Air C4[�+1ltion il�g :} '1'usinuur[1r Gs:4uj�:ar+L'y r, 131SSinL:Ss BUlLD1NG ;TYI_E, PRIMARY STRUCTURE lnciuscrial 1"Itch Cont.:tuj:c.r"ry Loon cabin Ochoer 1uis4d if ranch m.tnsiC,i1 Duj�lux . ad3itian , wl4ut will ua;u b+:'t �jalit l&:v4l Old sCy14 U "&4LJ.. 1ow ` C"VQ Cqd Cott""%: Oclwr ' ACCESSORY 13UILDING- GniwT' S4GiV orowf & House ' Ut�:ta,ched gar:.ge/one car/ two car/ Car CIRCLI CHI: PLEArE ) ' 7iCtachucl cja,ragula�r+s car two c"�a�yr cu c s s s * r ■ * r M s s s f~ L�riV:xt4 .toc:,4ge building 1:: .°STIMATPO MARKET VALUE OF CON r '1' Ft U C 'l• I U N � % r _ _ . � _ _ _ _ ago INVOTiAu►TTON ON nUrLOING SPECIPTCAT70US , ON REVERSE: SIOC OF 'PHIS SHUET, ggm 8E COMPLCTI.0 ! Form BPA 10/88 V1 BUILDING PERMIT APPLICATION CONTINUED - BUILDING SPECIFICATIONS : i Type of construction , wood frame , fire- safetetc . = .: J ._ . . � r a Will any second-hand or ungraded lumber be used? if so , for what ? Foundation wall material , s Thickness.} Depth of foundation below grade ( to bottom of footing ) A , Will there he a cellar ? Heated or unheated? Floor sq , footage sq ft Will there be a basement? x - , Will any portion be used as living space? ( If scat what portion? sq , ft . - - Type of use? Type of roof - sloped/flat/shed/other Material of roof i Size , wood stu.ds�" X spacing 4 ''o " o . c , length ft . � + 7oists ( floor beams ) lst . floor " X spacing d " o . c . span ft , ,joists ( floor beams ) 2nd . floor - ^�'"X spacing. ! LL '"o . c . span £t . Overlays ( ceiling beams ) " X spacing "o . c . span ft . Roof rafters "X " spacing o . c , span f t . Roof trusses {pre- engineered} spacings " o . c . span ft . Exterior wall finish 1 , of what material? Interior wall finish if a garage is to he 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? Height above roof- . ft . Depth of chimney foundation below grade ft . Depth of fireplace hearth ft , in . water supply - Municipal or private well 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) DEC LA RATION 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, whether specified or not , and that such work is authorized by the owner. Signature L' Own r,�ownerll agent , architect, contractor * * * Y It It i * * * x * * * * * * / k * x * t Y * I * It k SPECIAL CONDITIONS OF THE PERMIT - ......... ............ 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 . Gross floor area �- 1 71 2 . Type of heat /'-' 5- Ady!61 3 . Is the building mechanically cooled ?� /) " a' 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 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 B . Under 16 % Only 1 . R value of roof and floors exposed to ambient conditions. K — 3 Cs 2 . R value of exterior walls l*,- } 3 . R value of glazed area ors (� 4 . R value of doors ?Y 5 . R value of floors over unheated spaces f • . 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 1 . Thermostat maximum heat setting D . Duct Systems 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 . P ±Eing Insulation 1 . Size of hot water or cooling carrying agent pipe 2 . R value of pipe insulationi F . Service Water Heating 1 . Performance efficiency_ 2 . Temperature control sett g maximum G . For Swimming Pool Only 1 . Maximum heating Telephone No . �Appirfcantws signature ) TOWN OF QUEENSBURY APPLICA77ON FOR. r fy SEPTIC DISPOSAL PERMIT DATE C LOCATION OF PROPERTY FOR INSTALLATION Owner's Name: ! i Telephone; 6p 3 / Address : �f �" d� e�i)r I+L)I&LIV eA If If 11 e1 ! k/ 5 Installer's Name:_ a ct 09&c.iI / Telephone: Number of bedrooms (residential only) Total daily flow (compute (d 150 gal per bedroom ) Ll 1p Topography: Circle one: P�Loarn Roiling Steep Slope Qb of Slope Soil Nature: Circle one: Clay Other !Depth: Feet Ground Water : At what depth ? 4 �IR6 Feet Bedrock or Impervious Material. At what depth ? Feet Percolation test : Circle one. not require required rate min. inch. ---- Domestic water supply: circle one: Zuni Well Other If domestic water supply is a well: Separation : Water supply from septic absorption feet PROPOSED SYSTEM . Septic Tank / OOeQ gal. ( minimum size: 1 , 000 gal. ) TILE FIELD: Each Trench feet/Total system length ) K 7 feet SEEPAGE PIT(S): Number of / Size each feet by feet Size of stone to be used # /Depth or Thickness feet I have read the regulation on the reverse side of t et and agree to abide by these and all requirements of the Town of Quee oaatg�e -Disposal Ordinance. SIGNATURE OF RESPON,*S^IBLE PERS DATE : f'i/ � N 7 6P /� OVER 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 Canks , distribution boxes , the fields and. / or drywells B . Nu system shall be covered before inspection and approval by the .suildinb Inspector . Failure to comply with this requirement may Icsult in the uncoverin{; of the system by the installer and a fine ut 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 , ❑ . Should unforeseen problems during construction prevent proper installa— tion , alteration or repair of an approved system , a new pf0pusal must L4 submitLed to the Queensbury Building Department before further cuListruction . Town of Queensbury BUILDING and CODES DEPARTMENT Bay and Haviland Roads Queensbury , New York 12804 kemarks : , TOWN OF QUEE,NSBURY 13UILDXNG AND CODES DEPARTMENT 13AY & UAVILAND ROADS �2g04 ( } QUEENSBURY . NEW YORK TELEPHdNE ( 518 ) 792-5832 BuIlDING INSPECTOR"S REP©RT R rNSPEC'TIOM RECEIVED - RES7DEST -� NAME LOCATION/ PERMIT # __�!P-- APPROVED DATE YES NO FWTINOIPIERS RMS POUR MONOLITHIC _P FING FOUNDA'TIONNIDANPAL ,BAG KFILL ROUGH PLUMBING ,W PPAMING OUGH_IN ELECTRICALS INSULATXON= i FOUNDATION F RS ALLS CEILING TION : FINAL XIVSFEC CHIMNEY HEX(3HT poop.T NG SIDING EXTERNAL P�L7RCHL�SIS'PEPS�---�--`- } XTERS-CLEARAri" & RAILS ---'�-�-^��' PLUMBING FSXV�j ,RESIRELIEF VALVE INTERIOR TR141PRXVACY DOORS-�— FINISHED FROOFINGS GARAGE FIRE , DOOR CLOS.ERt S ) SMOKE DETECTORS INSPEGTXdN �_�---- --- FINAL ELECTRICAL FINAL APPROVp�' OF CONSTRUCTION______ OCCUPANCY MUST BE A SIGNED CERTIFICATE OF DEPARTMENT BEFORE T UILDING pgTAINED FROM HE BOCCUPIED ! TFIESE PREMISES ARE REMARKS : �f vy` INSPECTOR �ateen � +huer�. ©w+i ©T BUILDING and ZONING DEPRFA Box 98 Bay and Havifand Soed, R.D. Queensbury, New York 12801 INSCTION SEPT DIS SAL gYST 17 jf PERMIT NO - DATE Clay -�----- Sang YES - NOSOIL *TYPE "Testy N Re�I-red? percolation rate \- Niin/Inch percolatIon TYPE of SYSTEKW t tal ngth yr Absorption S Length 'If each tren Depth of trenches Size ofgravel PITS-kt4�,er o Gravel size Si p Ip ING : Bldg . to tar" Co TanX to dis't • Dist . bQX to field/ partial Openings sealed? YES j g�TION/SEPARA'TICNS L r -ft. Foundation to tanit ft. to to ©" -� t. abso Foundation to lot in's t. A so: ion one] I f~ circle Separation Of T Of3 pRCpERTY t side T TTT ft side Rig Front - Rear ,1 CaV4MT1 ' U` + ES No SYSTM4 USE APPROVED F3u i.la ing Inspector 0l/86 and s OWN OF QUEERS DE , OWNBUILDING AND CODES DERY PARTMENT k BAY & HAVILAND ROADS X28(7� OUEENSBURY. NEW YORK TELEPHONE ( 538 ) 7921-5832 BUI�Ir�G INSPECT©R t'Epopff xNSpSCTION RECEIVED REQUEST FOR NAME -7 C, LOCATION pERMIT __----- APPROVED DATE -- YES NO FOOTINGIPTERS S MONOLITHIC POUp FORMS FOUNDATIONAL P OVAL BACKFILL PLLIMBIN ROUGH FRAMING IN ELECTRICAL ROU f INSULATION : Iw FOUNDATION FLOORS WALLS CEILING FINAL INSPECTION : CHIMNEY HEIGHT ROOFING SIDING__------- H TEPS EXTERNAL PORCHEST ESI AILS_. -- - STAIRS-CLEARANCE & PLUMBING p TXTUR,R VACYI EDOVALVE ,INTERIOR TRIM/ FINISHED FAO 5 GARAGE FIRED FxNG DOOR CLOSER ) DETE ORS SMOKE CAL INSPECTION FINAL ELECTR FINAL APPRO AL OF CONSTRUCTxON OF OC MCUPANCY MUST BE A SIGNED ERTIFICA BUILDING DEPARTENT BEFORE ROM THE OBTAINED ARE OCCUPIED :' THESE PRE ISES-, . REMARKS : i INSPECTOR TONIN OF 'QVE'ENSBUR''r BUILDING AND CODES DEPARTMENT Y & HAVII.AAND ROADS I2$01- SA QUEENSBURY . NEW YORK 792_ 5832 TELEPHONE l5lg } �3� INS ZNSPEMOR' S lilEp Rr RECErVED 13 --� R xNSPECTxoN .� REQugsT�.�f NAME LiOCATrON ,EpMIT #-- 1-' `APPROVED DATE _�-'-----a" YES N17 FOOTING1PTE DOUR FORMSl-- MONOLITHIC P�pROOFING_�- �- MONO FOUNDATION/DAM BAC KF I LL APPRaVAL��- ROUGH PLUMBING FRAMING GH-IN ELECTR T ON ROU --- FOUNDATION . FLOORS � WALLS V- CEILING INSPEC TSOF1 : _d* FINAL HEIGHT CHIMNEY ROOFING SrDING pORCHESI TEP EXTERNAL RANCE RA I & STArRS-CLE�Xx,UR STREET VALVE PLUMBING TRIM/ RIVACY D RS E ., - ----- INTRIOR ISFINISHED WFING GAI FIRED DOOR CLOSER EC ORs rN SMOKE DET CAL SPECTION_f-�,.,---"' FINAL ELECTV L OF CONSTRiIC2ION 1 ------ 1. FINAL APPRC' OCCUPANCY MUST BE BUILDING T DEPARTMEN BEFORE A SIGNED C TIFICATE OF M THE OBTAINED I ES ARE OCCUPIED ! THESE REMARFCS = /T f INSPECTOR 'f fJ�3I� OV LQIJ1,ENS-513R*y TMENT AND CODES rY AR BUILDING D ROADS �1 BAY & HAVILAN6W PORK 1280 QUEENSBURY . { 5Z8 ) 792-5832 TELEPHONE I, PdR'T �I�ING 1I,ISPEGT R S - RECEIVED l. - - --- RE(jVEST FOR INSPECTION NAME �} / LOCATION pERNJIT # O n �^ APPROVED DATE / -� __'.`�.— - -- YES NO FOOTING/PIER FORMS._-� MONOLITHIC POT7RP,F,RCKaFING- E APPROVAL ACKFILL �r / tOt]GH PLUM RAMIN RGITJGH-IN�--" ELECTRICAL INSULATION : � - FOUNDATION�----'�_ F1.00ROS — WALLS f� _"-� If I CEILING QN - y. SPECT FINAL INS 1�C HI EY _-- HEIGHT ---�" --------- MN - - ROOFING_��-- SIDING pORCHE ISTEPS�--- r--- EXTERNAI & RAILS VALVE STAIRS�CLEARAN. ES/RELIEF PTdJMBING FIX PRIVACY DOORS_ ------ INTERIOR TRI P FINISHED F FING GARAGE FIREROQ DOOR CLOSE pETE TOR5IN5�'0 ELE SMOK C ICAL FINAL OF CONSTRUCTION FINAL APPRO AL ,OCCUPANCY MUST BE NT BEFORE OM THE BUILDING DEPARTME A SIGNED RT21G"ICA7'E QF OBTAINED IS ES ARE OCCUPIED THESE PREIII III I REMARKS = INSP TOR T Il OF Q 5 � BUILDING ANDD CODES DE DEPARTMENT BAY & HAVILAND ROADS 228Oa- QUEENSBURY. NEW YORK TELEPHONE ( 518 ) 792-5832 SUIIAING INSPECTOR' S REPORT R %rXSPECTION RECEIVED REQUEST FO RECEI Gf NAME , rJ LOCATION PERMIT DATE APPROVED YES O TINGIPrsuR FORMS - MONOLITHIC ' FORM r' CNDATION/ FoAC�,KFILL APPROVAL ROUGH PLUMBING ps FRAMING GH—IN ELECTRICAL ROU sr INSULATION: FOUNDATION FLOORS WALLS CEILING TION : `r FINAL INSPEC CHIMNEY HEIGHT ■' ROOFING SIDING pORCHESIs7`�P EXTERNAL LS STAIRS VALVE & L VALVE PLUMBING FIXTURESIRE INTERIOR TRIMIFRIVA Y b(jORS FINISHED FLOORS GARAGE FIREPROOFIh€G DOOR CLOSERS� _ ~�~ SMOKE DETECTORSz NSPECTION� �-— FINAL OLECTRAPPROVAL O CAL CONSTRUCTION_ -- FINAL OF OCCUPANCY MUST BE CERTIFI BCATE DEPARTMENT BEFORE A SIGNED UILDING OBTAINED FROM THE OCCUPIED1 THESE PREMISES ARE �~ SPEC�OR TOWN OF QUEENSBURY rNG AND CODES DEPARTMENT HZJxLD BAY N HAVXLA,ND ROADS 2805� RK QUEENSBURY, 5E8 ) YOg2- 5832 TELEPHONE BUILDING INSPECTOR' S REPORT Ci -S �' -- PECTION RECEIVED REQUEST FOR IN NAME LOCATION PERMIT ,DATE J APPROVED YES NO L�IfOOTINGIPIERS.J„ NOLXTHSC POUR ,FORMS G_l�- FOUNDATSONIDAMP- p BACF,F.TLL APPROVAL ROUGH PLUMBING FRAMING ELECTRICAL ROUGH-IN INSULATION: FOUNDATION FLOORS WALLS CEILING FINAL INSPECTION = r CHIMNEY HEIGHT ROOFING SIDING STEPS EXTERNAL PORCHESI & RAILS STAIRS-CLEARANCA PLUMBINGFIXTUORsIRELIEF VALVE INTERIOR TRrM1PRIVACY DOORS_ --- FINISHED �pFSN�i GARAGE FIREA9`Z DOOR CLOSERX S) SMOKE DETECTORS INSPECTION FINAL ELECTRICAL FINAL APPROVAL OF CONSTR"CTYON_�� OCCU -- A SIGNED CERTIFICATE OF PANCY MUST PARTMENT BEFORE OBTAINED PREMISESFROM THE BU OCCUPIEDiE THESE REMARKS : &��` U'� K !t' 0.7 G� (� ,XII A wtea, 4' Xx� c INSPECTOR SELECT BUSINESS FORMS (609) 848-5203 APPLICATION FOR ELECTRICAL INSPECTION # PLEASE BEAR DOWN YOU ARE (MAKING (4) COPIES i MIDDLE DEPARTMENT INSPECTION AGENCY, INC. L -- National Headquarters 900 Haddon Ave., Collingswood, N.J. 08108 {late : may � 1 City, Town or Township C7I ��, L County '1 10LOV rin" State �• ." . Location/Address P i'fi —'' c r^ r "1 r j� 1' j r4n421% —J'' ( if Located in Rural Area - P1ease` Attach Directions) Pole # Owner EJ 'j '{ ,A n -, j _" Y" S Permit * I Occupied As Building: New= Old Q Occupant Work Area in Building Floor 4*, etc. ) : App. for. Wiring 0 Service or: Ready for Inspection : Fee Remitted • $ Cash Q Check Q M.O. Q Make Payable To : M. D. I.A. Number of Rough Wiring Outlets Elect. Heat I 1 500 1 750 1000 1250 1500 1750 2000 2250 2500 2750 3000 Switches Amp. Service Surface Unit Dishwasher Range Lighting Water Heater Air Conditioner Dryer Pump Receptacles Number of Fixtures Oven Garbage Disposal Wiring and Controls for Burner Amp. Receptacles Fractional H-P. Vent Fans Other Equipment: MOTORS HIP, 1/2 1/12 1/10 1/9 1 /6 1/4 1/3 112 3/4 1 1 11/t 1 2 1 3 1 5 1 711z 1 le 1 15 1 20 I 25 1 30 1 40 1 50 1 75 100 Mark Number of Each Site App Iicant"s Signature r �- License # Permit # T/A Utility Applicant's4ddress _ FCC da 6oI Cr it? INAriAE} (OFFICE LCICATICIN (City) '- 1 4 tti (State) # (zip) l;F&b Service Request Phone # Lp 02 Electrician : :1 to * a DATE RECEIVED: DATE INSPECTED : Correct Location : Same as Above Q or : Red Notice Label 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 MOTORS H.P. 11/;W1 1/12 1/10 1/9 1/6 1/4 1/3 1/2 3/4 1 j 114 2 3 5 7112 10 15 20 25 30 1 40 1 50 175 300 Mark Numlaer of Each Size 500 750 1001' 0 125 1 50,1 1750 7000 2250 2500 2750 3000 �^ Patrick J ;�a=�,rlaa t_ 'Heat PO P1ox 341 NA1d5e�A Falls , ' 'i IIL 3 518/798-3473 ELECT$ICAL iNSPECIOR CERTIFlICATHMM USE FOR INITIAL VISIT ONLY NOTIFIED DATE OOnnecT FRIF FEE PAID Q RW Progress: Inc. C] LKD Q Contractor Q CFT Violation : Work Comp. Inc. 0 CASH Q L/A Owner Fee [] K L/A Due M # IPA Municipal I N # V # Date : Other Side Q Utility Applicant Owner Cut in Card 0 Temp # Date I IUC6c/"TlIOC CIf:AIATI IRF � c I.rk 1�t 1 IrOWN OF ©U'EENSBUR Y Y Zoning Admi it+tS x F-^tai-1 4twe*17 .37 � /ab -