POOL-0316-2022 SWIMMING POOL Office Use only
PERMIT APPLICATION
Permit M Pev�-' �3((e
Town.of eZeensbury $ 1 y y
742 Bay Road,Queensbury,NY 12804 Permit Fee: (7 Invoice#: G
P:518-761-8256 www.gueensbury.net Flood Zone? Y Reviewed Bya�
Project Location: r73S - IDo1-i �1%.�/ {����( Duct^syur�
Tax Map ID#: mil• -- .l'- `� Subdivision.Name:
Proposed.InstalI Date:
MAY 2-3 2022
SWIMMING POOL INFORMATION: TOWN OF QUEENS
&.CODES
CHOOSE ONE: "—ABOVE.-GROUND ✓ IN-GR
UNHEATED HEATED (pool cover heater, R-12 req'd)
SIZE OF POOL:
MANUFACTURER: �oHa.l
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 If;for-any reason,the buildin&permit application is withdrawn; 30%of the fee is retained by the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: l acknowledge-no construction.activities shall be commenced prior to issuance of a valid permit.
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.
have read and agree two the above:
PRINT NAME:
SIGNATURE: 60A DATE: Ur 23 26
Swimming Pool Packet Reviseditiarch 2022
0
d
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN, EMAIL
• Applicant:
Name(s):
Mailing Address, C/S/Z: 7 3s m• Hiit Rai
Cell Phone: Land Line: � --;--
Email: -er-7 rw( co,,
• Primar Owners :
Name(s): Ui4et
Mailing Address, C/S/Z: Say'
Cell Phone:._( S« . ) 53u-oys.' Land Line: _( —j--
Email:
❑ 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): _SzFF (NL4�1r-
Contractor Trade: 1q(?WJ C Mco�al►rcu l pobl f
Mailing Address, C/S/Z: 2(,8 Rd. C�rM���dq NY
Cell Phone:_( 516 ) 75l-&631 Land Line: _( --i—
Email: C ,i4;cw6w(u/poi)ls6?o ,,fl,C�ti,
**Workers' Comp documentation must be submitted with this application**
Contact Person for Compliance in regards to this project:
Cell Phone:_ S1`6 ) i3i3-' �39l Land Line:
Email: s-u Ahoy
— Swimming Pool Packet Revised March 2022
Oct. 13. 2022 12:00P%&—MDIA No. 0261 P. 3/4
MIDDLE DEPARTMENT INSPECTION AGENCY, INC.
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: Jeff Grenier Date:
o9r2st2o22
Occupant: Same Location,
738 Moon Hill Rd.
Occupancy:Swimming Pool Queensbury,Warren Co. NY
Applicant.
Phoenix Electric '
834 Seminary St " �'
D
Fort Edward, NY 12828
20221
TO of,Ctl1EENSBURY
Joseph A.Holmes.' ' l�ILDING 8t CODES
No. _148099172590EL„
Equipment: ;
2-Switches;2-Receptacles; 1 -LV Fli ttire;'"1 -'Burn•er,"Wiring &Controls for Gas;`1'=Pool Pump; 1 -60A Sub Panel;
1 -Light Shed
This certificate applies to the electrical wiring to the electrical equipment listed immediately null and void. rnIs certificate applies only to tree use,occupancy and
above and the instailafion inspected as of the above noted date based on a visual ownership as indicated nerein, Upon a change in the us*,occupancy or ownership
inspection. No warranty is expressed or implied as to the mechanical safety,OR- of the property indicated above,this ceitticato shall be immedlately null and void.
cleney or fitness of the equipment for any particular purpose. This certificate shall in the event that this certificate becomes invalld based upon the above condigons,
be valid for a period of one year from the above noted date. Should the electrical this certificate may be revalldated upon reinspection by Middle Department
system to which this certificate 6ppiies 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 dete,this certificate shall be process. A tee will be charged for this senfias.
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