POOL-0418-2020 " SWIMMING POOL PERMIT APPLICATION Office Use Only
Permit#: NIL--0,60 e)- 20 20
Town of Quccnsbury
Permit Fee:$ 1 ; Invoice#:26cC1
742 Bay Road,Queensbury, NY 12804
P:518-761-8256 www.queensbury.net Notes:
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Project Location: Q è37o{t Msbo(Lik 3'/ 1) b Oq
Tax Map ID #: '77 CI 1,0 4 1 L I 3 z Subdivision Nam D
JUL 2 3 2020 j
RY
CONTACT INFORMATION: TOWN Es S
BUILDDINGG&&C COODES _„_,,
• Applicat t: -,
Name(s): 1_3 ft 1 i e 1 ( � ) (-A k.
Mailing Address, C/S/Z: e t,Oonct fL'
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Cell Phon : ( 5i ) Land Line: ( )
Email: CL) r I , C 0
• Primary Own
Name(s): Da. ► e ' 1 e 0 StinAK
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Mailing Address C/S/Z: 5 le i���A � r - 0U- is 00(1 1,-) (Cell Phone: , 1 Lan Line:
Email: a&n ve 1 f 1'Y1 o 1 'Ir1 GL I r C C�Y (11
❑ Check if all work will be performed by homeowner only
• Installer/Builder: Workers' Comp documentation must be submitted with this application
Contact Name(s): ey( a C e }-\-{'. \) .e nS o in
Contractor Trade: li V Ca( V1`�
Mailing Address C/S/Z: I VC i 1S(y' ry(-4- Aryl P \i /,7?-)=1
Cell Phone: _( I ) 1 ,)(17L-1 Land Line: _( )
Email:
**List all additional contractors on the back of this form
Contact Person .or Buil in & Code Compliance: 0 i( \t - MaxiC ( JV�
Cell Phone: - Land Line: ��
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Email: 6.a� � e. � mil-kiorI( ci TUGC.( 1 . C0 YY`
Swimming Pool Packet Revised May 2020
• Installer/Builder: Workers' Comp documentation must be submitted with this ap lication
Contact Name(s): U W S S vi C
ContraMailing
Trade: • 000 S e+ I7 l {k P 1�-) vi P ` 143.3q
Mailin Address, C/S/Z: .�j �t I ` l
Cell Phone: _( t3 Ig) Land Line: _(
Email: , I YY) yl� S 0 L Ci+ t i n k , f-4
• Installer/Builder: W ers' Comp cume'ntatio must be submitted with this application
Contact Name(s): a( �yl FJ9 L hails DI)V i2Y
Contractor Trade: )e (`r
Mailing Addres C/S/Z:
Cell Phone: _( ) 5S,5 2 SO ? 7 Land Line: _(
Email:
• Installer/Builder: Workers' Comp documentation must be submitted with this application
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _(
Email:
• Installer/Builder: Workers' Comp documentation must be submitted with this application
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _(
Email:
• Installer/Builder: Workers' Comp documentation must be submitted with this application
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _( )
Email:
Swimming Pool Packet Revised May 2020
SWIMMING POOL INFORMATION:
CIRCLE ONE: ABOVE- GROUND (-IN-GROUND
SIZE OF POOL: ' 0 lc
MANUFACTURER: no\ phlo Poo \ S
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. 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: Oaat -e11-e S PrI(tk
SIGNATURE: DATE: 4.).. .,,?)/_1
Swimming Pool Packet Revised May 2020
RECEIVED
JUL 2 4 2020 t Ni
TOWN OF QUEENSBURY
ZONING OFFICE
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EDC-„ESNo,D0 OR
REVISED
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296.14-1-32 P001-0418-2020
Smith, Danielle
25 Edgewood Dr ���
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RX Date/Time 06/0812021 13:28 15182731202 No. 6893 P. 4/4
Jun. B. 2021" 1 :06PNPMMDIA
MIDDLE DEPAR ENS' INSPECTION AGENCY, INC.
Weiq that the electrical wiring to the lectrical equipment listed below has been examined and is approved as
being in accord with the National Electrical Co , applicable governmental, utility and Agency rules in effect on the date
noted below and is issued subject to the l'ollowi conditions.
Owner: Smith i Date:
05l21/2Q21
Occupant: I Locatio
Pool �5 Edgewood Dr.
Occupancy-
Pool Queensbury,Warren Co. NY
Applicant:
Smith
25 Edgewood Dr.
Queensbury, NY 12804
Joseph A.Holmes
No. 316014152141 EL
Equipment:
1 -Low Voltage Fixture; 1 -Pool Pump
. . � . ::.. . :. .. . . .:. . . boo•L � °�t � • ZO ZIJ
EC E9
J U N 0 9 .2021
TOWN-OF QUEENSBURY
BUILDING& CODES
This certificate applies to the electrical wiring to the electrical equip ent 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 n a visuaf ownership as Indicated herein. Upon a change in the use,occupancy or ownership
inspection. No warranty is a-Tressed or implied as to the mechanical�5 fety,effi- of the property indicated above,this certificate strall be Immediately null and void,
i ciency or fitness of the equipment for any particular purpose. This ce tale shall In the event that this certificate becomes invalld based upon the above conditions,
be valid for a period of one year from the above noted date. Should tl} electrical this certificate may be revalidated upon reinspection by Middle Department
system to which this certificate applies be tittered In any way,including lu not limit. Inspection Agency,Inc, An application for inspection must be submitted to Middle
ad to,the introduction of additional electrical equipment and/or the repip ement of Department Inspection Agency, Inc.to initiate the Inspection and revalldation
any of the components installed as of the above noted date,this certific t shall be process. Afee will be charged for this service.
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