POOL-0476-2021 QL :..,,SWIMMING POOL office use only
PERMIT APPLICATION Permit#: POOL—0V 7 zU7.L
Town of Queensbury Permit Fee:$ 01"Glnvoice#: L
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.gueensburv.net iewed By:
�zs�vU� 0rOrIV-1- D
Project Location: ',11g loury ' yv/ W01
K'�iax Map ID#: Subdivision Name: JUN 2 1 2021
TOWN OF QUEENSBURY
Proposed Install Date: 1 p�0' a d a I BUILDING &CODES
SWIMMING POOL INFORMATION: .
CHOOSE ONE: ABOVE-GROUND IN-GROUND
SIZE OF POOL: r 5 d 1 f ko L)A 0\/
MANUFACTURER: 5t'TAKR_r 1.tAA
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 If, for any reason, the building permit application is withdrawn, 30% of the fee is retained by the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: 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:
Swimming Pool Packet Revised December 2020
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• A nt:
Name(s): f fsG
Mailing Address, C/S/Z: 6 IKGW
Cell Phone: Land-EhTe: $f$ - `j q6 _ q'�
Email: rze �ti�k�� Ia.34 e n^oi �� ,I�
• Primary Owneds):
Name(s); Lv�kr\ 9 . 1:2 � J a s A
Mailing Address, C/S/Z:_6 R� Upl Y-Or Q v eenSbv y
Cell Phone: Lent-Me: 61 S --3aa _--7 6 'J
Email: L,,,,\ FP 34v— e, 5 mq,t 1 , C �
Check if all work will be performed by property owner only.
• Installer/Builder: (List all additional contractors on the back of this form)
Contact Name(s): 00 e— Go,K`0� J 'I cc \
Contractor Trade: Co Vt M � Vvv Y a
Mailing Address, C/S/Z: 19
Cell Phone: . Lam-Ume.: ��� ✓ q,56 —6 q
Email: MO C '- 1Sfa v\A.e rPopls - Co
"Workers' Comp documentation must be submitted with this application"
Contact Person for Compliance in regards to this project: M �rvh 0.✓\
Cell Phone: LamWae: -Tt
Email:
Swimming Pool Packet Revised December 2020
Inspector's No.: . ).2 I ::Z, -�. .
COMMONWEALTH.ELECTRICAL INSPECTION SERVICE, INC. - I. 9' 1.
(Consulting.and Fire.Inspection.Services)
(Incorporated in the states of New York, Pennsylvania; and West Virginia).
Desiring Certificate of Approval,application is made for inspection of electrical installation in the premises described below. On '
demand, applicant agrees to pay for inspection service in accord with schedule of charges.
Owner:. ! r.icf=2�.. /-/s A•c_ 2 `.
Type Building:Dwelling Other.(please specify); ;
Job:Location (-, R sr A � State: .0 'I
County: \A 'I Permit From: Permit#-
•
Swimmming Pool: Inground: Aboveground: . Bonding Date:
Work—New Additional Bldg.— New Old Ready for Inspection
Applicants Signature: . License#:
Please Print Name: .. Phone#:
Applicants Address: . Name Of Utility!
City: r : Office To Be.
State: Zip: : Notified Job#;
SPACE BELOW FOR USE OF INSPECTORS ONLY
Switches Water Heater Service Equipment Other list below
Receptacles .. . Paddle Fan/Light control Service Equipment
GFCI Recept . . .. Paddle Fan Panel
AMP Recept Paddle,Fan/Light Dryer Rec •
Lights . Vent Fan Washer Rec.
Lights Air Conditioner. . , _ . Dishwasher Rec-" -- -
Smoke Detectors AFC! Breaker Microwave Rec -
Smoke/CO Detectors GFCI Breaker ., Garbage Disp Rec
AFCUGFCI Breakers , Refrigerator Receptacle
Additional apparatus for certificate:(Not listed above) Inspector Job Notes:
R ON MUMBLO
ElectricaiIn pestor .
1 State Street
glens Falls, NY 1.2801
(518) 798-0905
Installed By(if other:than,applicant): ,
OFFICE USE ONLY
Date Received: Extra trip dates Inspection Fee$ /.<a n
Service Date: 1 1 CASH .
Certificate No: R.W.Date: - 2 Check No.
Final Date: ` '7_ I- `I 3. Invoice .
Certificate Needed? 4 "CC •
. .
Date Sent: Inspector sign in
Yes Dup next space i r
Please print name Inspector:
Original Progress Final .
THIS APPLICATION EXPIRES ONE YEAR FROM DATE MAKE ALL FEES PAYABLE TO C.E.I.S.INC.
.• .
JUN 2 1 2�2
TOWN OF QUEENSBURY
BUILDING +OQS_� ik �� �
('CAS e
TOWN OF QUEENSBURY
TOWN OF QUEENSBURY
BUILDING DEPARTMENT BUILDING & CODES DEPT.
Based on our limited examination,compliance
,, with our comments shall not be construed as Reviewed By: 6"C
indicating the plans and specifications are in
full compliance with the Building Codes of. Date:
New York State.
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PPP {pE �y
ATTENTION HOME ®W ER
6
Please assure you are familiar with the Pool i
Enclosure requirements specific to your
s l.
You are required to meet all applicable code' `
regarding swimmingF
pools, spas & hot tubs
at the time of inspection.
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