POOL-0045-2022 r�2 SWIMMING POOL office Use only _
f Permit#: (�UL —QU�S ��Z'2_
PERMIT APPLICATION
Town of Queensbury Permit Fee:$ �- Op nvoice#: I Cr
4
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.gueensbury.net Flood Zone? Y N Reviewed
Project Location: S L nun D r Iyej,Gu e erns ,WYu , NY 12. �"
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Tax Map ID #: �q , bd - J'T Sub 'Jame: L uhln ES+QtyS
Proposed Install Date: D It 0/2 Z
FES, 092022
OWN
SWIMMING POOL INFORMATION: r BUL a DIG COD DRY
CODES
CHOOSE ONE: _ABOVE-GROUND IN-GROUND
UNHEATED HEATED (pool cover heater, R-12 req'd)
SIZE OF POOL: N- L
MANUFACTURER: P[Qtinm YODI S
MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY): /
Steel/Vinyl V Fiberglass Gunite Poured Concrete y 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 If,for any reason, the building permit application is withdrawn, 30% of the fee is retained by the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 theabove:PRINT NAME: aV n Kd bhe/y
SIGNATURE: K11bJU)',J DATE: VI ZZ
Swimming Pool Packet Revised November 2021
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CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): LQUY 1
Mailing Address, 9)ikgel
Cell Phone: ( `� Land Line: �)
Email: QUybC1K 10IOJIM6. DOM
• Primary Owner(s):
Name(s):
Mailing Address, C/S/Z: O \
Cell Phone:_( �)�-q -(�� Land Line: _( )
Email JzQ UVbr\ �qc Cl�� Gom
❑ Check if all work will be performed by property owner only
• Installer Contractor: (List all addition I contractors on the back of this form)
Contact Name(s): W
Contractor Trade:
Mailing Address, C S/Z: \ 2
Cell Phone:—(- ) ,Gl�- Lg2q Land Line: _( )
Email: 5DIUSo�ObDD- 0 M
**Workers' Comp documentation must be submitted with this application**
Contact Person for Compliancein regards to this project: Dmt) ScmdL� P-vtoA
Cell Phone: ) 19 j- 2.C12 Land Line:
Email: SQJUSJ3,)(4V\0D.
Swimming Pool Packet Revised November 2021
ATTENTION HOME OW CO 0 N
.' 0 `r
Please assure you are familiar with the Poo TOWN OF QUEENSBURY
Enclosure requirements specific to our l BUILDING DEPARTMENT , c
q pe Y P� , Based on our{invited examination,corn
You are required to meet all applicable code with our comments shall not be constr ied a
regarding swimmi IS spas hot tubs indicating the plans and specifications are in O CD
C
e9 9 MJ pools, Pa full compliance with the Building Codes o p
at the time of inspection, 4, New York State.
l- FILE COPY
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