POOL-0088-2021 SWIMMING POOL -. office use only:...
PERMIT APPLICATION Permit.#: {2yUL OD
Town 606fQ60m.ury , Oinvoice
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.gueensbury.net 7 Reviewed By.
MAR 0 2 -2021 ,.
Project Location:::
TOWN.OF QUEENSBURY ..
Tax Map ID#: Subdivision:Name:
BUILDING.&CODES
Proposed Install Date: . ... . . .
SWIMMING POOL INFORMATION:
CHOOSE.ONE: ABOVE- GROUND IN-GROUND
SIZE.OF.POOL:
MANUFACTURER:: -
MATERIALS USED IN CONSTRUCTION (CHECK,ALL THAT APPLY):
(St6D�vvi�y Fiberglass Gunite: .:;; oured Concret -: Other ..
ADDITIONAL IMPORTANT INFORMATION:
:. 1. Any changes to the:app,roved plans prior to-or during construction will re:quire: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 If,for any reason,the building permit application is withdrawn,,30%'of the fee is retained by the.::;: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.,
Declaratiow:l acknowledge no construction:activities shall be commenced prior to issuance'of a valid permit.
retained.-
certify.that:the.application; plans and supporting materials.are a true and complete statement/d.escription of_.
the work proposed; that all work will-be performed in accordance with the NYS: Building Cod es,:loccaI building=
laws arld'ordiiiances and Jhc6nf6rmance With,;local: zoning regulations. I acknowledge-that I have;read thie
application and plot plan requirements anal 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: er,
w%� 0"
SIGNATURE:, i c - DATE: '
Swimming Pool Packet Revised.December 2020,
t
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): kP lr1
Mailing Address, C/S/Z: (� �;4�C w��� G-i-
Cell Phone: Land Line:
Email: d e�rry i� 3 a7@ $I -d-com
• Primary Owner(s):
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): N/61-4 TO TwY 5c��z5
Contractor Trade: f ob L 111-iI94,110-
Mailing Address, C/S/Z: 9 � 1,06V
Cell Phone: Land Line: T13- q p 63
Email:
C **Workers' Comp documentation must be submitted with this application**
7 ►n Earan ce cm(�4y 5 Send ai, 4�. -�L 6,n
Contact Person for Compliance in regards to this project:
Cell Phone: Land Line:
Email:
Swimming Pool Packet Revised December 2020