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POOL-0489-2021 ti SWIMMING POOL office Use only PERMIT APPLICATION Permit#: Town of Queensbury 742 Bay Road,Queensbury,NY 12804 Permit Fee:$ Invoice#:K} : ��n P:518-761-8256 www.gueensbury.net Flood Zone? Y N Reviewed By: V Project Location: q?, Fpy. �eX Tax Map ID#: Subdivision Name: 2-b cc . 1 -- \ -Az— Proposed JUN 2 8 �OZ� Install Date: TOWN OF QUEENSBURY SWIMMING POOL INFORMATION: BUILDING COf?EE g CHOOSE ONE: ABOVE-GROUND IN-GROUND i SIZE OF POOL: \ �� MANUFACTURER: ���\1� -�����`�-;�N MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY): Steel/Vinyl Fiberglass Gunite Poured Concrete OtherC������� 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 If,for any reason,the building permit application is withdrawn, 30% of the fee is retained by the Town of Queensbury.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 I� e CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL • Applicant: Name(s): 'moo Mailing Address C S Z: / / Cell Phone: Land Line: Email: ���� • Primary Owneds): ';Z� � Name(s): Mailing Address, C/S/Z: Cell Phone: Land Line: Email: 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: Cell Phone: Land Line: P��ce,ir�k' Email: G Swimming Pool Packet Revised December 2020 • 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: �- > <\i�r�S "Workers' Comp documentation must be submitted with this application" S .Q. ������-• • 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" • 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: -S;;z4, "Workers" Comp documentation must be submitted with this application" • 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" Swimming Pool Packet Revised December 2020 RX Date/Time 1110212021 13:04 15182731202 P.003 Nov, 2. 2021112;39P MDIA No, a2aa P. 3/5 MIDDLE DEPARTMENT INSPECTION AGENCY, INC. W*W*that the electrical wiring to the electrical equipment listed below has been examined and is approved as being in accord with the National Electrical Code, applicable governmental, utility and Agency rules in effect on the date noted below and is issued subject to the following conditions. Owner: Jo Marie Lockey . Date: 10/2212021 Occupant: Same Locatio . n92 Fox Road Occupan,ySWmming Pool Queensbury;Warren Co. NY Applicant: Brown Brother's Elec. Inc. • 175 State Rt 149 _ _, ,• n� Lake George, NY 12845.• _ '�•l�Q�" L J IDk06 i Joseph A.Holmes'. O©Y. No. .1440031551.4.OEL Equipment: 1 -Twist Lock Receptacle; 3 LV Controls-•forG rE FE l . gloy'U 3 2021 -... TOWN OF QUEEiNSHURY �.. , 3UILM .:�l� ; Cr? i=S This eertifcate applies to the eiectrieal wiring to the electrical equipment iisted immediately null and void, This certificate applies only to the use,occupancy and above and the installation inspected as oP 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 indicated above,this certificate snail be immediately null and void. rsency or fiptess of the equipment far any particular purpose. This certificate shall In the event that this certificate becomes invalid based upon the above conditions, be valid for a period of one year from the above noted date. Shouid the electrical this certificate may be revalidated upon relnspection by Middle Department system to which this certificate applies De altered in any way,including but not limit- Inspeedgrt Agency,Inc. An application�r inspection must be submitted to Middle ed to,the introtluction of add)tional electrical equipment and/or the replacement of Oeparfment Inspection Agency, Inc.to initiate the inspection and revalidation any of the components installed as oP the above note4 date,this certificate shall be process, A re6 will be charged for this service. y OWN OF QUEENSBURY ,BUILDING DEPARTMENT N Al Based o our limited examination,compliance EFNV3UR with ourtomments shall not be construed as wN pF QU EPA i indicati*.the plans and specifications are in TO CQf�ES �' j full compliance with the Building Codes of LNG & New York State. B S i� Revt,eW6 B�° 2 , ®ate. i V 1 ! i ) I 1 i k-0 too -- �K �y \ pcq 2b; j f 0 i I i VIOL I FORCY s ' �o . I f ( kk i j AMENTION HOME OWNER Pleas® assure you are familiar with the Pool Enclosure requirements spscflc-to your pool. I I ? You are required to meet all applicable codes i regarding swimming pools spas & hot tubs at the time of Inspection. I