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1989-460 i. _ . . .: rrra : «i:._;.� ...,;r r. ::. .Ri,_ , ,��. ::-v�_+_i�'9T ..;A ;.:¢„yr r -• s�S a-^- �qp-.r..r•irlcf�'Fi+an"r..-^e .. bgw ,. ".-yr�- '-'sc . . _ n CERTIFICATE OF .. OCCUPANCY €; TOWN OF QUEENSSURY I WARREN COUNTY, NEW YORK { Date _ September 13 i9 $; This is to certify that work requested to be done as shown by Permit Nov 89- 460 { has been completed. This structure may be occupied as a S i n a l p Family Ulyg i T i n g Location U4E=44k Lady Slipper Drive j ckvner Forest Wood Hom a i i fBy Order Town Hoard TOWN OF QUEENSBVRY ' f Director of Bldg. ac Code Enforcement i f I BUILDING PERMIT Q z TOWN OF +QUEENSBURY No. 89-460 WARREN COUNTY, NEW Y©RK PERMISSION is hereby granted to FOREST WOOD HOMES C OWNER of property located at LOT 18 LADY SLIPPER DRIVE Street, Road or Ave_ in the Town of Queensbury, To Construct or place a SINGLE 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. ti 1. OWNER'S Address is O fi HC-02 BOX 286P tiARRENSSURG , N . Y . 12885 2. CONTRACTOR or BUI LIDER"S Name SELF ra 3_ CONTRACTOR or BUILDER'S Address SAME 4. ARCHITECTS Name r- C s- 5_ ARCHITECT'S Address ; c• 4 V 6. TYPE of Construction — (Please indicate by XI CD fi7 1 Wood Frame ( y Masonry ( ) Steal [ I TCy 7. PLANS and Specifications !U No. 1370 sq . ft . Single Family Dwelling as per plot plan , specifications , and application including septic , attached two car S. Proposed Use SINGLE FAMILY DIJELLING u� m $ 203 . 00 PERMIT FEE PAID — THIS PERMIT EXPIRES January 1 79 90 �, (If a Io nger period is required an application for an extension mush be made to the Building and Zoning inspector of the town of Queensbury before the expiration date.) _ Dated at the Town of Queensbury this h Day of ,Tune 19 89 � m SIGNED BY for the Town of Queensbury Building and Zoning Trispector aq de A !' f ! YL 1 x rinkr r . iU' IL I `IC ANT) i N ? Ni 1 rR �1LT 'TOWN OF QUEE.�SBURYIddIdddddd— L'.7. C t - t �V Ott . ,�'`�` P�v i ?�rcd� TOWN OF OUEEENS13URY �, r cCEIVF"'7 Fee. rand JUN 1 1989 BU I LD I NO AND CODES ui .I7ARTt"E T Date Ta,6 "c d �r1Y :and HAVILiND RCAD.S RD 1 BOX :33 BL'©G• $ CODE DEP• r•7UEENSBURY , NE{J YCRN ] �c7FJ PeAnvi t No . " Tel . ( 518 ) 792 - 5332 Ext 204 r ■ x w w r x or x x x x x ; • x t x r + x r x r r . r r r r • • ■ A 1' Eiti1IT " S'C Ba OBTAINED BEFORE LECINPIINC, CONSTRUCTION . NO INSPECTIONS tk ILL BL MADE UNTIL APPLICANT HAS RECEIVED A VALID BUILDINC PERMIT . A11 appl icabl . spaces on this application must be corstT+ leted aria the •; � r* nature of the applicant must appear on the reverse sick of this sheet M ,� * f x i x * � 1 '111ie owner of this property is : •^J' F; � � � 1° , O . Address _ h -• 4 r , TAX MAP NO . / r ijroperty location L -- �: . Reiv ttas there been any split4 of this Jproperty since October YeS � no � if yes , Planning So .ard Review is necessary . LOT ND . CLUB 3IVISION NAME , IF APPLICAnLE 'i' he person. responsible for supurvision of wort: as regards Building Codes - . . 7 • , � _. T EL . NO . NAM , c, . AOL� acss Tel Name of builder } 4 i ; ... , : Address Tel r,t.I of Plumber - F.ddress Tel Name Of Mason A�.ldroa5 k ,t t �.tiTURs= 4f" f'[:C]pCY�L D 4.i1t:r- : ? (7NIf; G I N 1 01 71% 1A AT I ortica use 0n3y � r ZONING:, 02SICNATION OF PROPERTY /Cnn : truccicr� Of a ttiuw Auildin7 AdJition to lauila "g PERMITTED PRINCIPAL PERMITTED ACCESSORY. riltr: i .tibn to a 1.uilding REVIEW REQUIR - D - PLANNING SOARD ZONING BOARDi � , tao c17.71 :IL] u to .: xC � CiOr cl mCnI' ian:; � * APPROVED DATE urwtiur work {,..iu�crik��� 1 SITE. PLAN REVIEW 0 �— --- . VARIANCE If ttPPR0VF.D. . DATE v: iKi� :: S 11ttL: .1 s:.lL' L' L2ClPQ5L' La, � 'P [� UL 'L' llFt� # sq ft .fr�C /f Remarks L .jt Floor JJ ' _ ? n d Floor - s q f C . 77 5 ; CO1nP [.L:"L'L sNl`OL MA'1'lON Lint 54I1cLt] LS6 LLw1 . . ally' of I7rol7� rty w L' t x 1 t . Other F100rs sq fc ' Lxi ::Lii7c� I:uilli77�3 [ % 1 71 016: xrc . ( not collar or b :asQment ) TOTAL FLOOR ARGA � sq f It r Lx1oCi+1g L7u11J ►f7.J ( �• � Ua� -- u' i : u ue new sCructuru ft x C • ft + dl:: cancu trO�n L, ra1�urty lino �'ca.u �d:. cion-pier/ :lak,/cr:awl/L3atts ..1/ lull L'rapa�ea6 1vuilaing , I ft (eircly OnQ ) * Front yard_ _ ft Rear yurd� NQ4 of stories {kk" i. czabls: „ et and 3 rc Sid4 yard:: ��,_ It� i.ght ( Uradu to ridge. ) fro if on corner , :.ur.Ls.aCk from sidu str�cc�_rc If r0aicientiI no . of familia+ 5 * OCCU'A1Vr:Y INFORMATION Noe of rQo&s* { cxaludinq b"Chad) r tLb . of budrooimx r pRl. ftY iiUILOINL: Hoe or bloc lrooLux; �yCin+a fan►ily dwellinq [•riuury [iw.► ciarcJ ::y::twu� ----- i'wa t.+uuily dwulliny 1y17u of fuel rL►altli�l�s lwuiling / Nu:mbar of units. of firuplaCw:: tru Li : inzt:.114d � " Liastimutissnt oaeun:arcay W111 ;A woQU ZiUQWS3 L� i +4yt:wllut3?� � * 1•ran�ia:icC cioculy:arcc/ +L"nt.r.+l Air COO ua;.Ciun.i.rkg.' UU1LDING STYL_C, i'RjmARY STRUCTURE . Inctusx:rial c]c too r `Lunch' Conc�u�l.c.r..ry Lc.c? calain 1i ..ddiciun , w17.at Will U4.I 13+s? L ..i5wd ranch LMunxicu► oul,lux Ltui4. .+ iCrl r luvvl old � cy1Q � ACCe3soRY uuILnINCr L.7}su Cod C4Ct;ac1e� Octwr . " Cacharl ysraage/Ono Car/ t �c _c:ar CaLoni..l 1cOw S'Owit House CIRCLL� CNC PLIKKI 1 ' e_.�1Cetacriu❑ 9 "I"IOu/Oawa cur two c:+r cup ■ a a • • w ■ • • r r r r r r * 17riv" LQ SCQC"9Q building Y_ _^. '1' TT1AR• 1: 0 MAR1C [:'1• VA1. LfG 4s" r ��Ochaor r 7: OK ::•1• KUCTIQN 7fdraRriJ1T3i3h! ON pUiLCYiric SPI'CII' ICATIONS , ON TtEVERSI~ SIQ1 aF 'PIlIS SFtkE^L' , 'SC 9G COMtALI 'Z'l%L3L Farm tBPA I0188 V2 SUI :DING aEc'2, IT APPL =CATI^:N BUI `DING SPECIFICATIONS : Type Of construction , wood fra.,,e , _ . re safe , etc _ x: " Lll any second-hand or ungraded Z ur4 er be used ? If so , for what ? Foundation wall material Thickness Depth of foundation below grade ( to bottom of footing ) Will there be a cellar ? Heated or unheated? Floor sq . footage s Will there be a basement ? Will any portion be used as living space ? g ft ( If so , what portion ? sq . ft . - - Type of use ? Type of roof - sloped/flat/shed/other Material of roof Iw Size , wood studs , " X " spacing O . C . length ft . joists { floor beams ) 1st . floor `t spacing " o . c , span ft . Joists ( floor beams ) 2nd . floor X spacing span ft . cverlays ( ceiling beams ) "X " spacing, " o . c . span ft . Roof rafters XP1spacing o , c . span ft . Roof trusses ( pre-engineered ) spacing 1ho . c . span ft . Exterior wall finish Of what material ? Interior wall finish If a garage is to be attached , descri,te 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 he providedI ? 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 ar 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 ) D E C L A R A T 1 0 I3 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 pr emisc4S 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 Owner, a ner's agent, architect , contractor SPECIAL CONDITIONS OF THE PERMIT : By TOWN OF QUEENSBURY WARREN COUNTY , NEW YORK Application for : BUILDING PERMIT IN COMPLIANCE WITH THE NEW YORK STATE ENERGY CONSERVATION CODE A permit must be obtained before beginning work . ANSWER ALL of the following : 1 . Gross floor area F l 2 . Type of heat ��_, 3 . Is the building mechanically cooled ? 4 , Percentage of area of windows and doors A . Over 16 Only 1 . U 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 10 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 Bo Under 16 % Only 1 . R value o roof and floors exposed to ambient conditions 2 . R value of exterior walls _ 1 3 , R value of glazed area 4 . R value of doors 5 . R value of floors over heated spaces r 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 ) 14 . 'Type of insulation C , Controls 1 . Thermostat maximum heat set ng D , Duct Systems ^` 1 . is duct system installed in unheated spaces ? [YES NO a . if YES , R value of duct installation i - b . R value of duct in other areas E . _Piping Insulation 1 . Size of hat water or cooling carrying agent pipe 2 . R value of pipe insulation F . Service Water Heatin 1 . Performance efficiency 2 . Temperature control setting maximum G . For SwimmingPool Onl 1 . Maximum heating Telephone No , ( applicant ' s signature ) O WN OF Q UEENSE UP Y `A-------- APPLICATION FOR SEPTIC DISPOSAL PERMIT DATE Nlr� 7 J 71 ■ LOCATION OF PROPERTY FOR INSTALLATION 104 1$ Owner's Name: A.l * I%y. Telephone: Address: Ur Installer's Name: baud Telephone : I Number of bedrooms (residential only) . _ Total daily flow (compute (d 150 gal per bedroom) Ysb Topography: Circle one: la Rolling Steep Slope % of Slope Soil Nature: Circle one San ' Loam Clay Other /Depth : Feet Ground Water : At what depth ? 570 JfFeet Bedrock or Impervious Material: At^w—h�att�depth ? � eet Percolation test : Circle one: of required 1equired rate ruin, inch. Domestic water supply: circle one: nicipal Well Other If domestic water supply is a well: Separation : Water supply from septic absorption feet PROPOSED SYSTEM : Septic Tank � 6 gal. ( minimum size: 1 . 000 gal.) TILE FIELD : Each "french feet/Total system length , � � feet SEEPAGE PITS}: 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 this sheet and agree to abide by these and all requirements of the Town of Rueensbury Sanitary Sewage Disposal Ordinance , SIGNATURE OF RESPONSIBLE PERSON: DATE : ;. yx�� �; 19_ I . .. _., ., _._._ 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 hour e pre start of construction and skull include a plat plan showing : 1 � tnyj � 1 . } the proposed location of the system 2x 1.},� aszd anct� l to 4ante lines �`�5 . ibta��ioTr and *kance to structures 4 . ) location ai7d• s iy e to any water �s4s �r ry( : 2tY .1.t 5 . ) size and dimensio�n�s' of all tanks , distribution boxes , rile fields and /o1 . d we 1 * �r+'� r � >� : �• r ► B No S Cs.CtF1,m , shah 'Pe covered before inspection and apprq�al ivy the 1' uilding 4 ;bai-s �pmulr . Failure to comply with this � �Pce'gtstirem no (ham; result in the uncovering; of the system by the installer and a fine cI up to $ 250 . 00 . C . An approved copy of the plot plan shall be available on the construction site . Failure to produce said p t�tao0lan at time of inspection may result in an immediate work stoppage . U . Should unforeseen problems during construction prevent proper installa— cioiz , alteration or repair of an approved system , a new proposal must be submitted to the Queensbury Building Department before further conzz truction . Town ofvQueansbury BUILDING and CODES DEPARTMENT Bay and Haviland Roads Queensbury , New York 12804 � s kt:marks ; a a, 4 , j TOWN OF QUEENSBURY BUILDING AND CODES DEPARTMENT BAY & HAVILAND ROADS 1 y QUEENSBURY, NEW YORK I280k TELEPHONE (518) 792-5832 BUILDING INSPECTOR. ' S REPORT REQUEST FOR INSPECTION RECEIVED J � NAME LOCATION DATE �j -" S a PERMIT #f!t APPROVED YES I NO FOOTING/PIERS MONOLITHIC POOU FORMS FOVNDATION/DAM PROOFING BACKFILL APPROV ROUGH PLUMBING FRAMING ELECTRICAL ROUGH- INSULATION: FOUNDATION FLOORS WALLS CEILING b/FINALL INSPECTION: CHIMNEY HEIGHT ROOFING L� SIDING EXTERNAL PORCHE /STEPS STAXRS-CLEARANgfE & RAILS PLUMBING FIX ES/RELIEF V LVE INTERIOR TRI PRIVACY DOORS H ED FINIS F RS GARAGE FIRE ROOFING DOOR CLOSE (S) �— SMOKE DR T TORS FINAL ELEC CAL INSPECTION FINAL APPRO AL OF CONSTRUCTION A SIGNED CERTIF-TCATE OF OCCUPANCY MUST BE OBTAINED FROM THE BUILDING DEPARTMENT BEFORE THESE PREMISES ARE OCCUPIED! REMARKS: INSPECTOR ,_.Lawn o� �u�enshtertd BUILDING and ZONING DEPARTMENT Bay and Haviland Road, R.D. 1 Box 98 Queensbury, New York 12801 SEPTIC DISPOSAL SYSTEM INSPECTION NAME LOCATION DATE L 'r PERMIT NO . SOIL TYPE - a Loam - C1aY - Percolation Test 'Required? YES - NO Percolation rate - Min/Inch - TYPE of SYSTEM : Absorption field , total length_,'�el� � Length of each trench tlC7 Depth of trenches Size of gravel SEEPAGE PITS#Number of) ,' � Size- ft. x Gravel size PIPING : Size Type Bldg . to tank *�� �- Tank to dist. bole' / Dist. box to f1(o Openings seals ? NO Partial LOCATION/SEP TIONS : Foundation tan e�C7 f t e Foundation o k.absorption eft . Absorption; to lot line eft. Separatioo of pits — ft- LOCATION bF SYSTEM ON PR.4PERTY (circle one) rt _ ear - Left side - Right side MENTS : SYSTEM USE APPROVED' L Bu ing Inspector 01/86 and vl TOWNOF QUEENSBURY BUILDUXLD ING AND CODES DEPARTMENT BAY & HAV.ILAND ROADS QUEENSBURyt NEW YORK I280k H 1 . TELEPHONE (528) 792-5832 BUILDING INSPECTOR ' S REPORT REQUEST FOR INSPECTION RECESVED__�C� - NAME LOCATION DATE ( t .PERMIT APPROVED YES NO FOOTING/PIERS MONOLITHIC POUR FORMS FOUNDATION/DAMP-PROQF;I NG BACKFILL .APPROVAL ROUGH PLUMb,2NG FRAMING ELECTRICAL R8 GH-IN L.IINSULATION.: `a, FOUNDATION FLOORS WALLS CEILING FINAL INSPECTION: CHIMNEY HEIGHT ROOFING SIDING EXTERNAL PORCHES/STEP STAIRS-CLEARANCE & .,,�Fmx PLUMBING FIXTURES/PELIE VALVE INTERIOR TRIM/PRT4VACY DO S FINISHED FLOORS GARAGE FIREPR ING DOOR CLOSERS) SMOKE DETECTO S FINAL ELECTRIC L INSPECTION FINAL APPROVA OF CONSTRUCTION A SIGNED CERTIFICATE OF OCCUPANCY MUST BE OBTAINED FROM THE BUILDING DEPARTMENT BEFORE THESE PREMISES ARE OCCUPIED: REMARKS; fr INSPECTOR TOWN OF QUEENSBURY BUILDING AND CODES DEPARTMENT BAY & HAVXLAND ROADS QUEENSBURY, NEW PORK 12809- TELEPHONE (518) 792-5832 BUILDING INSPECTOR ' S REPORT REQUEST POR XNSPECTXON RECEIVED NAME LOCATION DATE l —�— APPROVED YES 1 .1vo FOOTXNG/PXE MONOLITHIC R FORMS FOUNDATXONJD .PROOFXNG B>CKFXLL APPRO L &ORO GH PLUMBING M.I'NG ELECTRICAL ROUGH- N INSULATION: FOUNDATXON FLOORS WALLS CEXLXNG FINAL XNaSPECTION: CHIMNEY HEIGHT ROOFING SIDING a EXTERNAL PORCHES/SEEPS STAIRS-CLEARANCE ¢} RAXL PLUMBING FIXTUREyr/RELIEF ALVE INTERIOR TRXM/PJ,rXVACY DC3p FINISHED FLOOR GARAGE FXREFR7FING DOOR CLOSER ( .SMOKE P TECT!?RS FINAL ELHCTRX L XNSPECTXON FINAL APPROV+4L OF CONSTRUCTION A SIGNED CERTXF'XCATE OF OCCUPANCY MUST BE OBTAINED FROM THE ,BUILDING DEPARTMENT BEFORE TIIESE PREMXSES ARE OCCUPIED! REMARKS: INSPECTOR TOWN OF QUEENSBURY BUILDING AND CODES DEPARTMENT BAY & HAVILAND ROADS QUEENSBURY, NEW YORK I28OLL TELEPHONE (5161 792-5832 BUILDING INSPECTOR ' S REPORT REQUEST FOR INSPECTION RECEIVED !NAME LOCATION / DATE APPROVED YES NO FOOT-XNG/PS !!//MONOLITHIC riR��FORMS _ .......` FOUNDATION/DAMP—PROOFING BACKPXLL APPROVAL ROUGH PLUMBING FRAMING ELECTRICAL ROUGH— N INSULATION: FOUNDATION FLOORS WALLS _ CEILXNG FINAL INSPECTION: CHXMNEY HEIGHT ROOFING STRING EXTERNAL PORCHES/STEPS .tTATRS—CLEARANCE & RA PLUMBING FIXTURES/RE IEl' VALVE INTERIOR TRIMJPRIVA DOORS FXNXSHED FLOORS GARAGE FXREPROOFXN DOOR CLOSER (S) SMOKE DETECTORS F"TNAL ELECTRICAL X PECTION k FINAL APPROVAL OF ONSTRUCTION .s A .SIGNED CERTTFX TE OF OCCUPANCY`"MUST BE OBTAXNED FROM TH BUILDXNG DEPARTMA' 4VT BEFORE THESE PREMXSES A E OCCUPXED! REMARKS SNSPECTOR TOWN OF QUEENSBURY *grt/rJ- BUILDING AND CODES DEPARTMENT BAY & HAVILAND ROADS QUEENSBURYF NEW YORK 1 2804- TELEPHONE (518) 792-58.32 BUILDING INSPECTOR' S RE�^P�ORT REQUEST FOR INSPECTION RECEIVED l � � �1 NAME LOCAT,-I�yON DATE ] �`� PERMIT # APPROVED YES NO FOOTING/PIERS MONOLITHIC POUR FORMS UNDATIO Nf DAMP-PROOFING �Z3ACKFILL 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 FIXTURES1$?ELIEF VALVE INTERIOR TRIM/PRr,VACY DOORS FINISHED FLOORS GARAGE FIREPROOFING - DOOR CLOSER (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: INSPECTOR TOWN OF QUZENSBU'RY BUILDING AND CODES DEPARTMENT BAY 6 HAVILAND ROADS, NEW FORK TELEPHONE ( 518 ) 792-5832 BUILDING INSPECTOR.' S REPORT REQUEST FOR INSPECTION F2ECE2vED NAME LOCATION PERMI # J DATE APPROVED YE NO , OT114CTIPIERS FORMS MONOLITHIC POUR _PROOFING FOUNDATIONID L BACICV.rLL ROUGH PLUMBING FRAMING ROUGH" N ELECTRICAL INSULATION= FOUNDATION FLOORS WALLS CEILING FINAL IN �. CH,mmrY HEIGHT ROOFING y SIDING ST PS EXTERNAL ppRCHESI ILS STAIR.S�CL ARANR,ES/ ELIEF VATS F PLUMBING Cy DOORS ti INTERIOR TRrMI'PRI s FINISHED FLOORS GARAGE FIREPROOF" NG DOOR CLOSER (S ) SMOKE DETECTORS FINAL ELECTRICAL NSF'ECS'ION�� � �- FINAL APPROVAL OF CONSTRUCTION -- OCCUPANCY MUST BE ED E ii IFICA UIxDING DEPARTMENT BEFORE ASIGN FRT TBM THE E III OF OBTAINED THESE PREMISES ARE OCCUPIED!' REMARKS 1I INSPECTOR SELECT al-ISINESS FORMS (609) 848-5203 APPLICATION FOR ELECTRICAL INSPECTION PLEASE BEAR DOWN YOU ARE MAKING (4) COPIES { � MIDDLE DEPARTMENT INSPECTION AGENCY, INC. National Headquarters 900 Haddon Ave., Collingswood, N.J. 08108 * Date `- + .4, City, Town or Township DDUn#y �. State Location/Address 1C) + R c^ l• i~ � �� { f Loc d iibA Rural Ar lease Attach Directions) Pole # Owner 7"`7 " 1+ 11 1,3 f a s Permit # Occupied As Building. NevYEl OldO Occupant Work Area in Building Floor #, etc, ) : App. for: Wirin 0 Service Q or: Ready for Inspection : Fee Remitted - $ Cash Q Check Q M.O. = Make Payable To : M.D. I.A. 500 750 lOtlO 1254 1540 1750 2000 2250 2500 2750 3000 Number of Rough Wiring Outlets Elect. Heat Switches Lighting Amp- Service Surface Unit Dishwasher Flange Receptacles Water Heater Air Conditioner Dryer Pump Number of Fixtures Chen Garbage Disposal Wiring and Controls for Burner Amp. Receptacles Fractional H.P. Vent Fans Other Equipment: MOTORS FE,P. 1/2 1 12 1/10 1/8 111 1/3 1/2 3/4 1 lily 2 3 5 7112 1 10 1 15 1 20 1 25 1 30 40 50 75 1 100 Mark Nu r of Each SI Applicant's Signature -` License # Permit # T/A lqmN. Utility : NAME OF IC LOCATION) Applicant's Address: . . 15fi-te(City) 1A ) K l .. (y(state) _ M ,Y (Zip) lal ,y I: Service Request # Phone 12A I Electrician : ----------------------- a DATE RECEIVEO: DATE INSPECTED^ Correct Location : Same as Above 0 Of. Red Notice Label 0 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 Fl.P, 1120 1/12 1A0 1/S 1/6 1/4 1/3 1/2 3/4 1 14s 2 3 5 7Vz 10 15 20 25 30 40 50 75 100 Mark Numiler of Each Size Elect. Heat 500 1 750 1000 1254 1500 1750 2000 22S4 2500 2750 3004 CORRECT C>ERTIFFCNI1IONf U" FOII INITIAL V1ZVr0NLV _ NOTIFIED DATE FEE FEE PAID 0 RW Progress : Inc. Q LKD F`1 Contractor 0 CFT Violation : Work Comp. Q Inc. Q a L/A Owner CASH 0 L/A Fee CH K # IPA Due MO # Municipal INV sF Date : Other Side Q Utility Applicant Owner Cut in Card Q Temp # Date I RICI'I re'+Te'1f![+ [+�Y"R1I1 TI IIpVC ...err► f d+R' ' +L i6 ' j aAl G�S fir► fir► �* doew doomew r r *NW 'p � II LA i