POOL-0580-2021 SWIMMING POOL Office Use only
PERMIT APPLICATION
Permit#:
742 Bay Roa ,Queensbury,NY 12804 Permit Fee:$ :Invoice#: o
P:S18-761-82S6 www.aueensbury.net Flood Zone? Y N Reviewed By
Project Location: 10 va e-04-
Tax Map ID#: Subdivision Name: D L �n
Proposed Install Date: �/�
AUG 0 6 2021
SWIMMING POOL INFORMATION: TOWN OF QUEENSBURY
BUILDING&CODES
CHOOSE ONE: BOVE-GROUND IN-GROUND
SIZE OF POOL: 1 (, v 24 1
MANUFACTURER: kct•7 -le—
MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY):
Steel/Vinyl Fiberglass Gunite Poured Concrete Other a tvm;^VV&1
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 If,for any reason,the building permit application is withdrawn, 30%of the fee is retained by the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: DATE:
Swimming Pool Packet Revised December 2020
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Auolicant•
Name(s): i4Clg4., gay /-Te n n,'yew 10C k A".,
Mailing Address, C/S/Z: 1.0
Cell Phone: hand hine�,
Email: (� &?+ £sb�� �j 5! 8-9 3 a - .10 G 3
rw J , . ,
Primary Owneds):
Name(s):
Mailing Address, C/S/Z: rn� G�
Cell Phone: Land Line: ,5a
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):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
"Workers' Comp documentation must be submitted with this a[mlication"
Contact Person for Compliance in regards to this project:
Cell Phone: Land Line: Scl 3-2 _ 92 6 3
Email: ret,p� ��(P „y,-a"I , crn�•
1
Swimming Pool Packet Revised December 2020