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POOL-0568-2022
SWIMMING POOL office Use only PERMIT APPLICATION Permit#: ML_-arZ>b6- 20 z2- Town of Qgeensbury 742 Bay Road,Queensbury,NY 12804 Permit Fee:$ 1�j�D ;Invoice#: �� P:518-761-8256 www.gueensbury.net Flood Zone? Y Reviewed By� Project Location: 38 MEADOWVIEW RD Tax Map ID #: 297.17-1-65 - Subdivision Name: Proposed Install Date: 08/20/2022 pCCE9WE SWIMMING POOL INFORMATION (please fill out completely): TYPE: CHOOSE ONE: SEP 12 2022 X ABOVE-GROUND X UNHEATED TOWN OF QUEENSBURY BUILDING&CODES —IN-GROUND (inc. partially) —HEATED (pool cover heater, R-12 req'd.) COST OF CONSTRUCTION: $400 SIZE OF POOL: 27' ROUND MANUFACTURER: ATLANTIC/MODEL: ADMIRAL MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY): Steel/Vinyl X Fiberglass Gunite Poured Concrete Other Declaration: I acknowledge no additional 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 above: PRINT NAME: Rebecca A. Andre SIG NATUR : DATE: 9 /IgpOR,�;2— Swimming Pool Packet Revised July 2022 CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL • Applicant: Name(s): Rebecca A.Andre(Tax ID: Slattery) Mailing Address, C/S/Z: 38 MEADOMIEW RD., QUEENSBURY, NY 12804 Cell Phone: 5( 18 )932-9343 Land Line: � ) Email: RANDRE1010@GMAIL.COM • Primary Owner(s): Name(s): REBECCA A.ANDRE (SLATTERY) Mailing Address, C/S/Z: 38 MEADOMIEW RD., QUEENSBURY, NY 12804 Cell Phone:_(518 )932-9343 - Land Line: _( ) Email: RANDRE1010(aDGMAIL MM v Check if all work will be performed by property owner only • Installer/Contractor: (List all additional contractors on the back of this form) Contac Name(s tract o ): Con Tra e: Mailing Ad s, C/S/Z: Cell Pho _( ) 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 July 2022 OI QUEENSBURY tat.li!,_>jlf�i�� C�)�Eta DEFT, 9��vi�Llti� By.: — DO 14 SEP - 1' Fn - O NO- F - Ql)..M - -- BE- N� F - - .� AY-��;�,��:,- _ '= •_ BUILDING akt{� 11 55\)yy ' - „ 11001 OutltI NT9C?N HOME OVYNER,`' '" w timer ©u •�,;.;,�..,.h-::-� y�� J �.a�e��i61- �I��f.YVE671i8.•.r _ ".:s... iretllOnts S eci C$O,.yOUf p . �!''' 4 'Youere' ,to men 1 4pp116e .: s y �� •. � ,+r:'.":ice/•.yzrl" a- - - - - - - - •- ..tom. - ,'•y Y � -t'"., - 297.17-1-65 - POOL-0568-2022 Andre, Rebecca 38 Meadowview Rd Above ground pool ,Sep, 7, 2022912:58PNOMMDIA No. 0086 P. 6/6 MIDDLE DE AIZTMENT INSPECTION A ENCT� INC. liggd) ;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 governmental, utility and Agency rules in effect on the date noted below and is issued subject to the following conditions. Owner: Rebecca Andre Date: 08/29/2022 Occupant: Pool Location38 Meadow View Rd `. Occupancy-S,, ng Pool Queensbury,Warren Co. NY Applicant Mr. Electric of Queensbury Jeanne Dion PO fox 4304 L Queensbury, NY 12804 ; J Joseph A.Holmes , 147269171.950EL Equipment: 1 -Switch; 1 -GFCI Receptacle; 1 -Time Clock;•1 Twist-Lock Receptacle .. SEP 08 2022 TOWN OF QUEEN88URY ING&CODES This certificate applies to the electrical wiring to the electrical equipment listed immediately null and void, This certificate applies only to the use,occuVancy and j. 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 cenificete shaft be immediately null and void. ciency or fitness of the equipment for any particular purpose. This certificate shall In the event that INS certificate becomes Invalid based upon the above condtions, be wdr+d for a period of one year from the above nosed date. Should the electrical this certificate may be revalidated upon reinspeotion 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 j ed to,the introduction of additional electrical equipment and/or the replacement of Department Inspection Agency, Inc,to initiate the inspection and rsvalidetion any of the components installed as of the above noted date,this certificate shall be process. A fee will be charged for this service. r