POOL-0215-2023 •` 5
}\ ` SWIMMING POOL office Use only
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PERMIT APPLICATION Permit#:
Town-ofqueensbury Permi aiU, Invoice#:
742 Bay Road,Queensbury,NY 12804 D C E
P:518-761-8256 www.gueensbury.net —Fioed-7-qn .. Reviewed Bye,
MAY 0 4 2023 � LPJU
Project Location: C �
iOWN^ OF QUEENS BURY
'1`�\ L�UILY !VL'�a �C1UES
Tax Map ID #: _3�S _ Its -- t 20 Subdivision Name:
Proposed Install Date:
SWIMMING POOL INFORMATION (please fill out completely):
TYPE: CHOOSE ONE:
ABOVE-GROUND UNHEATED
IN-GROUND (inc. partially) _ HEATED (pool cover heater, R-12 req'd.)
COST OF CONSTRUCTION:
SIZE OF POOL: u 2
MANUFACTURER: Nn S��&t\LT C;� -� � A-
MATERIALS USED-I1I•CONSTRUCTION (CHECK ALL THAT APPLY):
Steel/Vinyl Fiberglass Gunite Poured Concrete Other
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 above:
PRINT NAME:
SIGNATURE: DATE: c:�
Swimming Pool Packet Revised July 2022
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): hftj�fJ
Mailing Address, C/S/Z: �!A4 W Lku ,,wLx=p NY n
Cell Phone: Stilb ) 1.oe)-,� - 2-, s oo Land Line:
Email: _ R�y��� l_6��5\C-�t���1�v (2
• Primary Owner(s):
Name(s): lc-;ft IuG RS fyc Llul�
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line: _( )
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): )%%\.k y3aAeau
Contractor Trade: 5?ck>1
Mailing Address, C/S/Z:
Cell Phone:_( ��9 ) 9-01 — (c ow Land Line: _( )
Email:
"Workers' Comp documentation must be submitted with this application"
Contact Person for Compliance in regards to this project: N-W� _Lc^� -P�(3�y►�=
Cell Phone: ( ) Land Line: �)
Email:
Swimming Pool Packet Revised July 2022
!20/za, 8:38 AM
Town of Queensbury Interactive Mapper
v
Identifed Layer Queensbury Parcels v
FID 16655 1
!Polygon Shape J J
NEWNUMBER 1315.10-1-20
OWNERI ,REVIVAL DESIGNER HOMES LLC
OWNERMAILS 144 Wildwood PI
OWNERMA]IL4(Queensbury, NY
ZIPCODE 112804
GISACRES 12.32167
Town Of Queenshury Interactive Mapper
4"7
https://qbygis.queensbury.net/webapp/default.html?pid=315.10-1-20 1/2
21335
Insp. Date: 7/11/2023
Appl #: SH23838
ELECTRICAL CERTIFICATE
COMMONWEALTH ELECTRICAL
INSPECTION SERVICE, INC.
176 DOE RUN ROAD, MANHEIM, PA 17545
TELEPHONE: (717) 664-2347
New York Office: (585) 624-2380
Premises of: DAVID PREHODA as INGROUND POOL
Address: 751 CORINTH ROAD, QUEINSBURY NY
County of: WARREN Permit #: 215-2023
Installed by: GORDON JAMES
Apparatus: DISCONNECT, PUMP, GFCI BREAKER.
Inspected by: SCOTT HONSINGER
The conditions following governed issuance of this certificate, and any certificate previously
issued is cancelled. Failure to have the property reinspected when additional equipment or wiring is
added; or within one year fmm the date of the certificate shall void the certificate in its entirely and the
company shall not be liable for any damages whatsoever;
This certificate does not guarantee efficiency, wearing qualities, maintenance or repair and the
company shall not be liable for any damages resulting from any defect or fault in the plans or specifica-
tions, including repair, reconstruction, personal injury or for the death of any person; and
This certificate only covers visual inspection of wiring and does not cover manufacture or use
of wiring.
Inspectors of this Company shall have the privilege of mwung inspections at any time, and if
its rules are violated, the Company shall have the right to revoke the certificate,
All corrections must be requested within 60 days.