POOL-0511-2021 / k SWIMMING POOL Office Use only
PERMIT APPLICATION Permit#:
Town of Queensbury
742 Bay Road,Queensbury,NY 12804 Permit Fee:$ Invoice#:I�il
P:518-761-8256 www.gueensbury.net Flood Zone? Y N Reviewed By:
Project Location:
Ove /a 3-0
Tax Map ID#: Subdivision Name:.
Proposed Install Date: �Up���• d _�
SWIMMING POOL INFORMATION:
CHOOSE ONE: AB E-GR ND IN-GROUND
SIZE OF POOL: C E
NfANUFACTURER: �J'7 er1 a�
� JUL 0 7 202-1
MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY): 19
Steel/Vinyl Fiberglass Gunite Poured Concrete Other TOWN OF QUBBdVSBVF;YBUIL DING 81 CODES
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 If, for any reason, the building permit application is withdrawn, 30% of the fee is retained by the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 CQueensbury. 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: 16 erg' Me
:
SIGNATURE: � DATE:
Swimming Pool Packet Revised December 2020
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): l o i' ��ef-xme
oat van ,C/,�'► V� ���i� J� �
�,�� f� �
Mailing Address, C/S/Z: /6 0
Cell Phone: Lid-Hite: Ce-111%d,-ye- i �5 l? " a 0,c5�3
Email:
• Primary Owners
Name(s): 1.06j+C-h erl./Se- C�1"
Mailing Address, C/S/Z:
Cell Phone: Lire: C�/7,�
Email: Lb He e,-��k vo ccrr-7
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): oa1-5
Contractor Trade: Ao/ ioS-�a//e j^ r Y i 6 3 Lf
Mailing Address, C/S/Z: y-5 Ima,117Q�/e��/J SYJ�t'�� ��
Cell Phone: Land Line: 5 7 73 ® 07 Q 7
Email:
**Workers' Comp documentation must be submitted with this application**
, e
Contact Person for Compliance in regards to this project: 114
Cell Phone: Land Line:
Email: J
Swimming Pool Packet Revised December 2020
• Installer/Builder: (List all additional contractors on the back of this form) 1
Contact Name(s): �j�ar-� ;-d,� Fe vi Ce—d' �'®+�5��''vc�-i m'i — K6 ; I 1
Contractor Trade: (qes�Ae>7 J- ,k CI 0 CO 1-" rll e f c; ` --Peel i'Y1 S'�
Mailing Address, C/S/Z: � ,7 Ct^,'&JLry -f �LC4 il L , f f Va�S�n-� �lis �
Cell Phone: Land Line: �`3 r
Email:
o{
**Workers' Comp documentation must be submitted with this applicati n**
• 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:
**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
TOWN OF QUEENSBURY
BUILDING & CO EPTe
�ieviewe By:
Date: Z- W°
FILE COPY
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BUILDING DEPARTMENT
n A Based on our limited examination,compliance
with our comments shall not be construed as
C indicating the plans and specifications are in
c �,t�6�► full compliance with the Building Codes of
State.
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