POOL-0368-2023 : '
SWIMMING POOL Office Use Only
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PERMIT APPLICATION Permit#:
Town ofQueensbury
742 Bay Road,Queensbury,NY 12804 Permit Fee:$ Invoice#: 6.3
P:518-761-8256 www.gueensbury.net Flood Zone?• Reviewed By:
Project Location-. 0 1a\') �Vljb V
t�
Tax Map ID#:S��40 ZDL@5-14flSubdivision Name:
Proposed Install Date: 6 ^10 - nR__�) E C E 9 E
D
SWIMMING POOL INFORMATION (please fill out completely): JUN 2 G 2023
TYPE: CHOOSE ONE: TOWN OF QUEENSBURY
_ABOVE-GROUND _UNHEATED BUILDING&CODES
IN-GROUND(inc.partially) HEATED(pool cover heater, R-12 req'd.)
COST OF CONSTRUCTION: L y I `-a
SIZE OF POOL: )_Le Y_ M,
MANUFACTURER: -Od aL.te---�
MATERIALS USED IN 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. 1 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 abov�
PRINT NAME:�Jp��1__Jea� nuaA
- 10
SIGNATURE: DATE: tCk
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• A licant:
Name(s): V(1�
Mailing Address,C S/Z:.
Cell Phone: Land Line: �)
Email:
• Prima Owners
ih
Name(s): I Kow--,eJ
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): V') �s
Contractor Trade: Rom\ N,�,s�L\U-N
Mailing Address, C/S/Z: 5 fp4,n S) n r ✓ v ) z
.Cell Phone:_(SQ ) — T� Land L'ne:
'Email: lo �
"Workers' Coinp documentation must be submitted with this application"
Contact Person for Compliance in regards to this project: eon (5 I u S
Cell Phone: Land Line: ( )
Email:
� ECE0WE
TOWN OF QUEENSBURY
BUILDING DEPARTMENT b ��
v4se' on our limited examination,compliance
rue as
f: :ie plans and specificatioM-efe,n
t tlr mce with the Building Co*cofe■....,,,, j Ac¢F�,.�eA,z TOWN OF QUEENSBURY
HOME OWN R BUILDING& CODES_ . �;��_ 3 Ll C'-/
�e cWas� �tl
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Please assure you are famillar with the Pool
r hereby o■rtiiy that thin map was prepared !sw as
Enclosure requirements specific to your,pool. aotcal field ■nr.ey. Shia certification wall run only
to the person■ for--the surrey ran pnpatrad,•asd oa
APR 1 :.L,.,, his behalf to the VMS co■paay, Oora%s* tall)tge■oy aDd
You are required to meet all applicable codes^ r.eainq rnatiLneion listed hereon. Cartilitations ate
:J regarding swimming IS! Spas h tubs
net triulat:wL w additional institutions or
en g pools, & hot tuw ��e �t Donna C. Barrows
P^ at the time of Inspection. Certified To. Home Funding, Inc., c/o Republic Bancorp
i� mortgage Inc., its successors and/or assign
Nations Title Insurance of New York Inc.
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LAND SURVEYORS,GLENS FALLB,NM PORK
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11Y G.L.-Mr. 4 McCoA,MAuc N.Y. STATE LIC.NM 33617'
301.20-1-47 POOL-0368-2023
Rowell, David -
13 Lancestire Dr TOWK-OF QUEENSBURY
In ground pool 16 x 32 BUILDING & CO ES PT"
Reviewe By•
Date:.
23976
Insp. Date: 7/25/2023
Appl #: K23050
ELECTRICAL CERTIFICATE
COMMONWEALTH ELECTRICAL
INSPECTION SERVICE, INC.
176 DOE RUN ROAD, MANHEIM, PA 17545
TELEPHONE: (717) 664-2347
New York Office: (585) 624-2380
PrerniseS Of: DAVID ROWELL as INGROUND POOL
Address: 13 LANCESTIRE DRIVE, QUEENSBURY NY
County Of. WARREN Permit #: POOL 0368-2023
Installed by: POOLS PLUS
Apparatus: 220 VOLT115 AMP RECEPTACLE, I-GFCI RECEPTACLE, 1-WET NICHE LIGHT,
GROUNDING & BONDING, 1.85HP WATER PUMP, 1-20 AMP BREAKER, 15 AMP 2 POLE GFCI
BREAKER, PUMP TIMER. INGROUND POOL PER 2017 NEC ART 680.
Inspected by: MICHAEL KRATKY
'the conditions fallowing governed issuance of this certificate, and any cemificm previously
issued is cancelled. Failure to have the property reinspected when additional equipment or wiring is
added: or within one year $rem the date of the certificate shall void the certi8este in its entirely and the
company shall not be liable for any damages whatsoever,
This certificate does not guarantee effiiciency, wearing qualities, maintenance or repair uJ the
corripany shall not be liable for any damages resulting from any defect or fault in the plans or specifica-
tions, including repairs reconstruction, personal injury or for th c death of any person; and
This certificate only covers visual inspection of wiring and does not cover manufacture or use
of wiring.
Wspecka of this Company shall have the privilege of making 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 flays.