POOL-0035-2021 �I' q SWIMMING POOL office Use only
P
PERMIT APPLICATION Permit#: - ?A21
Town of Queensbury Permit Fee:$ i�Q" ; Invoice#:
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.gueensbury.net Flood Zone? Y N Reviewed By:
Project,Location: 177 Glen Lake Road, Lake George, NY
Tax Map ID#: 288.16- 1 -88 Subdivision Name:
Proposed Install Date:
DECLC �
SWIMMING POOL INFORMATION: JAB! 2 9 "20
21
CHOOSE ONE: _ABOVE-GROUND X IN-GROUND "OWN OF
SIZE OF POOL: 20�x 40� BUILDING 8,cOD URY
CODES
MANUFACTURER: PoolWarehouse
MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY):
Steel/Vinyl x 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 If, for any reason, the building permit application is withdrawn, 30% of the fee is retained by the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: 177 Glen Lake Rd, LLC /c/o Albert Gjonbalaj
SIGNATURE: DATE: 61 2S)262
Swimming Pool Packet Revised December 2020
a j
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): 177 Glen Lake Rd, LLC c/o Albert Gjonbalaj
Mailing Address, C/S/Z: 5 W 37th St, 12th Floor, New York, NY 10018
Cell Phone: 646 ) 542-4740 Land Line:
Email: albert(q_)stayatlina.com
• Primary Owneds):
Name(s): 177 Glen Lake Rd, LLC c/o Albert Gjonbalaj
Mailing Address, C/S/Z: 5 W 37th St, 12th Floor, New York. NY 10018
Cell Phone: _( 646 ) 542-4740 Land Line: _( )
Email: albert(o)stayatlina.com
I
® 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):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _( )
Email:
"Workers' Comp documentation must be submitted with this application"
Contact Person for Compliance in regards to this project: m p`%
Cell Phone: �_) Land Line: 0_6
Email:
Swimming Pool Packet Revised December 2020
RX Date/Time 0610712022 10:44 15182731202 P.003
Y "'Jun. 1. 2022—g10: 15AM• MDIA No. 9451 P. 3/4
MIDDLE DEPARTMENT INSp-pCT'ION AGEINCTy INC.
gam.that the electrical wiring to the electrical equipment listed below has been examined and is approved as
being in accord wiih the National Electrical Code, applicable govemmental, utility and Agency rules in effect on the date
noted below and is issued subject to the-following conditions.
Owner: 177 Glen Lake Rd. LLC
Date: 05/25/2032
'Occupant:
Same Location
177 Glen Lake Rd.
Occupancy wimmirig Pool Queensbury,Warren Co. NY
Applicani: Stay At Una
177 Glen Lake Rd. 20 21
Lake George, NY 12845
L J .
Joseph A,Holmes No. 148969169800EL._
Equipment: - -
5-SNltches; 1 -GFCI Receptacle; 1 -Burner;wfrrig'&Controls for'Ga!§1 -Pool Pump; 1 -Time Clock; 5-Pool
Lights(Outside of Pool Area);2-240V GFCI Breakers; 1 -15A AFCl/GFCI Breaker,2-20A GFCl/AFCf Breakers; 1 -
50ASub Panel
ILUN
TOWN OF QUEENSBURY
BUILDING&CODES
This certificate applies to the electrical wiring to the electrical equipment listed immediately null and void. This certificate applies only to the use,occupancy and
above and the installation inspsctad as of the above noted date based on a visual ownership as indicated herein. Upon a change in the use,occupancy or ownership
Inspection. No warranty is expressed or implied as to the mechanical safety,effi- of the property indlcated above,this certificate shall be Immediately null and void.
clency or fitness of toe equipment for any particular purpose. This certificate shall In the event that this certificate becomes invalid based upon the above conditions,
be vJid for a period of one year from the above noted date. Should the electrical this certificate may be revalidated upon reinspection by Middle Department
system to which this certificate applies be altered in any way,including but not limit- Inspection Agency,Inc, An application for inspection must be submitted to Middle
ed to,the introduction of additional electrical equipment and/or the replacement of Department Inspection Agency, Inc.to initiate the inspection and revalldation
any of the components installed as of the above noted.date,this certificate shall be process. A fee will be charged for this service.