POOL-0102-2021 �S
SWIMMING POOL office Use Only
1 PERMIT APPLICATION Permit#:
Town of Quecnsbury
742 Bay Road,Queensbury,NY 12804 Permit fee: Invoice#•$ �
P:518-761-8256 ww-w-7aueensbury.net Flood Zone? Y N Reviewed By:
Project Location: / — -�t • / �v\e
Tax p ID#: Subdivision Name:
a� ao- f- A,4
Proposed Install Date: t Y F— r 1 — J tln P2A Q-4
SWIMMING POOL INFORMATION: Lug
CHOOSE ONE: ABOVE-GROUND IN-GROUND I m LJ
SIZE OF POOL: L/X �g / , I I wa i
MANUFACTURER: 111'I12 Poo Oz
_ OQ
MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY): y, m
O
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 If, for any reason, the building permit application is withdrawn, 30% of the fee is retained by the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
* Applicant:
Name(s): J � l NfD COLA- /� I
Mailing Address, C/S/Z: -7L r w Ua4, / (� UCQiI� I�VirU t1 t� 12-rM4
Cell Phone: Land Line: 5-1� d
Email:
* Primary Owner(s):
Name(s): kjCYI N-D [GZ-!
Mailing Address, C/S/Z: V- it
Cell Phone: Land Line: 57b -)-(op 3(� Z-(.e J J
Email: rvv It ?, ett0-c L•cow----,
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): P1 t kf- n G 0-+ i
Contractor Trade: - 0 01 ns v.1 e
Mailing Address, C/S/Z: 300 v'v v�a Sat ( f-V✓�- d wgfd
Cell Phone: Land Line: 3 1o25-7 f y41 9216
Email:
**Workers' Comp documentation must be submitted with this application**
Contact Person for Compliance in regards to this project:
Cell Phone: Land Line:
Email:
S( i 30 � - vJ D3
e, AC-&,o S 10 ke% o • Co M
Swimming Pool Packet Revised December 2020
MAY 11 2021
TOWN OF QUEENSBURY
BUILDING & CODES
0 M2--
COMMONWEALTH ELECTRICAL INSPECTION SERVICE,INC.
Main 0111te 176 Doe Ron Road-Msitheim,PA 17545
M11N1C1PAL CERTIFICATF - ELECTRICAL APPROVAL
N
Pemit No........................ ........Celt N 2 42280 Cut-in Card No.....................................
Owner.............. .......
......................................................1......................
Location.........
....... ), . ...........................................................
Installation Consisting of.......... kn..... Um.,"
..1A .................
............................. ...............................................
.....................I.............. ....... ..........
......................... .................................... .....
InstalledBy....... ..............................................Lic. No.........................................
The conditions fo;imving triviismed the iss"nec of this certificate,and any certificate previously issued is
cancelled:-
1'h6 certificate only covers the electrical equipment and installation conditions as of date. Upon the
introduction of addifivr.lil equipment or alterations, application shall be promptly inside for inspection.
Inspectors Of this COW011Y shall have (lie privilege of making inspections at any fillie, and if its
rules are violated,the Company shall have the right wrevoke this corrificare. �4
6 bate.. .. ... ...... ...... INsrEc-r0R
Member N.F.P.A.,I.A.L.I.
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