POOL-0531-2021 4 lm SWIMMING POOL office Use Only
PERMIT APPLICATION Permit#: I�Ot�I 0 S 3 1 `
Town of Queer1 Ury
742 Bay Road,Queensbury;NY 128.04 Permit Fee:$ !yv,au ;Invoice#: 39Go
P:518-761-8256 www.4ueensbury.net Flood Zone? Y N Reviewed By:
Project Location: aI mcD)gn lO Orm-
aU-e-es�rux�i, V E
Tax.Map ID#: Subdivision Name:.
3.v , is- a- &5
JUL 14 2021
Proposed InstallZIate:
.. lit f�►Q��. TOWN OF QUCENSBUR`l
J. BUILDING 8, CODES
SWIMMING POOL INF.ORMATION:. -
CHOOSE ONE: ABOVE-GROUND IN- �OND
SIZE OFPO IL: I l4X t a
MANUFACTURER: �l �r,1I h0JQ
MATERIALS USED IN.,CONIS:T'RUCTION-(CHECK ALL THAT APPLY):
St el/Vi yl Fiberglass Gunite Pour Co crete 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2: If, for any reason,the building permit application is withdrawn, 30% of the'-fee is retained by the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 6.nd.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.requiremerits-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: �vv"1
SIGNATURE: DATE:
swimming Pool Packet Re0sed:December 202.0
CONTACT INFORMATION: PLEASE.PRINT LEGIBLY OR TYPE, PLEASE,INCLUDE AN EMAIL
• Applicant: . .
Name(s): Q(DLLqCOUP
TQ
Mailing Address, C/S/Z: &�l m ouw S- akt nS Fau I
Cell Phone: Land Line:. 51�S-a• �S-`-7o��y S �' )
Email: �11U
J @ (1n i�cCl- OBIS-CtSyn
• Primary Owner(s):
N.ame(s): Nc-to n
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email: �c ��_' ��� b°I c3o�.
- Check if all work will be performed by property owner
• Installer/Builder:(List all'additional contractors on the _back of this form)
Contact Name(s): �)j�,
Contractor Trade::.c3ta 1(�
Mailing Address, C/S/Z: ew_mS.FO-US) 04 ia�0
Cell Phone: Land.Line rJ -baS-1 513--1q$---10gq
Email: �C -1"e
**Workers' Comp documentation must be submitted with this application**
Contact Person for. Compliance.in regards to this project: � �
Cell Phone: Land Line: c�1'6=3LQ'\—(fag- 5 i B--I
Email:
LjnLiln--)ij-CCA Cum ,
Swimming Pool Packet Revised December 2020