POOL-0220-2022 w '
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SWIMMING POOL office Use Only
PERMIT APPLICATION
Permit#: I'oo
Town of Queens6nry �U,
742 Bay Road,Queensbury,NY 12804 Permit Fee:$ 1 ;Invoice#:
P:518-761-8256 www.aueensbury.net Flood Zone? Y tV Reviewed By�"�"')
Project Location: 1_7 e�Sg s
Tax Map ID #: 'Z��-�0_ r— � � Subdivi .io.n_Name ,
Proposed Install Date: ^
APR 2 7 2022
SWIMMING POOL INFORMATION: T®t/vRJ Or COi`:S13
BUILDING
&OC3E5
CHOOSE ONE: ABOVE-GROUND _IN-GROUND
UNHEATED HEATED (pool cover heater, R-12 req'd)
SIZE OF POOL: ��
MANUFACTURER: S�—
MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY):
Steel/Vinyl Fiberglass Gunite Poured Concrete Other
ADDITIONAL IMPORTANT INFORMATION:
1. Any changes to the approved plans prior to or during construction will require the submittal of
amended plans, additional reviews and re-approval.
2. If, for any reason,the building permit application is withdrawn, 30%of the fee is retained by the
Town of Queensbury. After 1 year from the initial application date, 100%of the fee is retained.
Declaration: I acknowledge no construction activities shall be commenced prior to issuance of a valid permit.
I certify that the application, plans and supporting materials are a true and complete statement/description of
the work proposed, that all work will be performed in accordance with the NYS Building Codes, local building
laws and ordinances and in conformance with local zoning regulations. I acknowledge that I have read the
application and plot plan requirements and I, or my agents, will obtain a certificate of compliance before use
of the pool.
I have read and agree to the bove:
PRINT NAME:
SIGNATURE: DATE:
Swimming Pool Packet Revised March 2022
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): M
Mailing Address, C/S/Z: Al IS09
Cell Phone: ( S S ) `�l 0 " S 13 7 Land Line: � )
Email: Pk AiZ3S- .CO W\
• Primary Owners • �`e`
Name(s): ,
Mailing Address, C/S/Z: 1-7 �tft s��l �-�.� ���✓� � �sy �� � ��
Cell Phone:_( \$ ) $0_ SJ Land Line: _( )
Email: d.vA . r C®V"\
'Check if all work will be performed by property owner only
• Installer/Contractor: (List all additional contractors on the back of this form)
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line: _(. )
Email:
"Workers' Comp documentation must be submitted with this application"
Contact Person for Compliance in regards to this project:
Cell Phone: Land Line: )
Email:
Swimming Pool Packet Revised March 2022
301.20-1-39 POOL-0220-2022
Matthew Shiel
17 Heresford Lane
Above ground swimming pool
` -- TOWN OF QUE NSSURY
EUILDit G & CODES DEPT.
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APR 2 7 222-
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BUILDING & CODES
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ATTENTION HOME O
Please assure you are familiar ith the Pool
Enclosure requirements specifi our Poor
7-1 You are required to meet all app is codes 4
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regarding swimming Pools, sp
at the time of inspection.
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RX Date/Time 06/22/2022 15:54 15182731202 P.002
Jun, 22. 20221 3;25P_ -MDIA No. 9554 P. 2
MIDDLE D.EPARMENT INSPECTION AGENCY, INC.
�osxCt4 that the electrical wiring to the electrical equipment listed below has been examined and is approved as
being in accord with the National Electrical Code, applicable govemmental, utility and Agency rules in effect on the date
noted below and is issued subject to the following conditions.
Owner. Matthew Shiel Date:
06/14/2022
Occupant: pool
Location17 Heresford lane
OccupancySwimming Pool Queensbury, Warren Co. NY
ApplicanF Matthew Shiel
17 Heresford Ln-
Queensbury, NY 12804: �•
Joseph A-Holmes .
No. ,1489791,7.0159EL'. -- - _ JUN .2 4
2o2p _
Equipment' TOWN 0C QU& ODESY
CODES
2-Switches; 1 -GFCI Receptacle; I -Tme-Clock .1 -•Twist•L•ock Receptacle BUILDING
Z113 2-2,
This certificate applies to the electrical wiring to the electrical equipment listed Immediately null and void, This certificate applies only to the use,occupancy and
above and the Installation Inspected as of the above noted date based on a visual ownership As indicated herein. Upon a change in the use,occupancy or ownership
inspection. No warranty is expressed or implied as to the mechanical safety,effi- of the property indicated above,this certificate shall be immediately null and void,
ciency or fitness of the equipment for any particular purpose. This certificate shall In the event that this certificate becomes invalid based upon the above conditions,
be valid for a period of one year from the above noted date. Should the electrical this certificate may be revalidated upon relnspectlon by Middle Department
system to which this certificate applies be altered In any way,including but not limit. Inspection Agency,Inc. An application for inspection must be submitted to Middle
ed to,the introduction of additional electrical equipment and/or the replacement of Department Inspection Agency, Inc.to initiate the inspection and revalidation
any of the components installed as of the above noted date,this certificate shall be process. A fee will be charged for this service,