POOL-0210-2021 SWIMMING POOL office Use only
PERMIT APPLICATION Permit#: 9PQA_. 0210 - Z42
Town ofQueensbnry Permit Fee:$ Invoice#:,f-)5`4 2
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.gueensbury.net Flood Zone? Y N Reviewed By:
Project Location: Bf'ril PA" Deye—
Tax Map ID#: as a a ` Subdivision Name: FAren tJCYTO a 0-RDve
Proposed Install Date:
SWIMMING POOL INFORMATION: U
APR 0 9 2021
CHOOSE ONE: ABOVE-GROUND _1/_IN-GROUND
TOWN OF QUEENSBURY
SIZE OF POOL: BUILDING&CODES
MANUFACTURER: C ire�5!!s fools
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 If,for any reason, the building permit application is withdrawn, 30% of the fee is retained by the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.
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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:
PRI T NT NAME:
JZIl&4
SIGNATURE: DATE: / .
Swimming Pool Packet Revised December 2020
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): �II�n-vv� Sale,/
Mailing Address, C/S/Z: ICI- Ncru Pa" [biz QUeeevS bur-/ /N /460-1'
Cell Phone: ( SI$. ) 79& - 5(oa2 Land Line: �)
Email: W I I I IA-M ShP,A 1.39 50 G MA1y CPw7
• Primary Owner(s):
Name(s): WilliAgn L aiDA
Mailing Address, C/S/Z: QLee -sburV, IVY 2;2r0!Vf
Cell Phone:_( 51$ ) 7%. - S/� 5� Land Line: '_( - )
Email: k)�11r i.�h�,a? L3? �/►��t, , fyM
0 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): PAT CoiPJ L-oid
Contractor Trade:
Mailing Address, C/S/Z: /15 WApL Q o,+.o ',LAY1h4-m /V V /at 10
Cell Phone:_( 511 ) 365 575 7 Land Line: _( _V'J ) "7$3 S,Z 3ca
Email: N c rr, m
**Wor ers'_Comp documentation must be submitted with this application**
Contact Person for Compliance in regards to this project: SAwlg-- -k, ���c .;r
Cell Phone: Land Line: � )
Email:
Swimming Pool Packet Revised December 2020
289.12-118 POOL-0210-2021
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TOWN OF QUEENSBURY
BUILDING DEPARTMENT
Based on our limited examination,co liance
with our comments shall not be cons ed as
TOWN OF QUEENSSURY indicating the plans and specificatio s are in
BUILDING CODES DEp hull compliance with the Building es of
® New York State. .
Reviewed B .0
Date: L
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