POOL-0318-2021 SWIMMING POOL Office Use only
PERMIT APPLICATION Permit#:
Toum ofQueensbury
Permit Fee:$_L
742 Bay Road,Queensbury,NY 12804 �Invoice#: b�b�l
P:518-761-8256 yryuw.gue2nsbury.net Flood Zone? Y N Reviewed By:
Project Location: (Q ` Co �kntf �0 �n
Tax Map ID#: Subdivision Name: D `I
Proposed Install Date: CAN& 0 (, rNt MAY 0 7 2021
TOWN OF QUEENSBURY
BUILDING&CODES
SWIMMING POOL INFORMATION:
-CHOOSE ONE: ABOVE-GROUND IN-GROUND
SIZE OF POOL: 1 5' I
MANUFACTURER:
MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY):
Stnyl 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 If,for any reason,the building permit application is withdrawn, 30%of the fee is retained by the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: ! ricJ DATE: lJ�
Swimming Pool Packet Revised December 2020
J
r
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• A scant•
Name(s): y r g�L�
Mailing Address, C/S/Z: f'�� cc�(.�o �ci ob(ecll (( Y/V y
C� �l��lVl y
Cell Phone: rJp f1 L���
Email: J'
fi Ch cD e Will k�s& mall wn
• Prima Primary Owners : \ �p
Name(s):
Mailing Addres§, C/S/Z: ' cub
Cell Phone: Laad±i=
Email: (_O�C �. AwxI ` COIF
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: Em
-- �Y J g51S ��c 0,,
�rnMailing Address, C/S/Z06>C
Cell Phone: Eattd-N;e: ISM $D I �cJ
Email: etN\�i���P00�SG.(�G�1D����GI�G�S C`Nf�A�\ . �0
"Workers' Comp documentation mustbe submitted with this application"
Contact Person for Compliance in regards to this project: �t 16
Cell Phone: L-aR�e: L+13
Email:
Swimming Pool Packet Revised December 2020
KIN
Za
'Mi
A"E
... ........
";.. ..............
go IM
IS
'0 Oil.
f, ti )�L�x :,{ h� ��v.`'i't'-'lye��•'•,`'���ro✓Y
P-4-
M
p
M
M E
4,4"t'
1700
_V.
52
"[-M X
fg i ,
ON M
—TN0Av fa a
�5'tft WI
............
.......... APA
296-15-1-8 POOL-0318-2021
Winters, Ray & N chcje
61 Country Club Rd
Above ground pool ;^_... _