POOL-0262-2022 o`I SWIMMING POOL office Use Only
PERMIT APPLICATION Permit#: NP -- 02-6Z- 2022
Town of Quee bsn ury
742 Bay Road,Queensbury,NY 12804 Permit Fee:$ l�,l
� �Invoice#: 9`j01
P:518-761-8256 www.gueensbury.net Flood Zone? YC/NUJ Reviewed By:
Project Location: S' Whispennq Pr,eS yvaY
Tax Map ID#: Subdivision Name: 7yneSvV UUCI
301 13-a- (91
Proposed Install Date: - urw- /fvl\/ 2-,022
SWIMMING POOL INFORMATION:
CHOOSE ONE: ABOVE-GROUND IN-GROUND I-�Ps��eC�
SIZE OF POOL: & X I(D l
MANUFACTURER: rnvvert O'l Pods PEE MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY): 7021Fiberglass Gunite Poured Concrete OtherBNSBURYr0®B5�_ -
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 If,for any reason,the building permit application is withdrawn, 30%of the fee is retained by the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: r✓n'?) I y Porte-e.slc
SIGNATURE: DATE: S aC)ao�
Swimming Pool Packet Revised December 2020
I
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): �IM 1/ 5- (,4 �d eye, G�uum '� n �/
bi 1 �'
`
Mailing Address, C/S Z: h,7p-P,Or C�
Cell Phone: L
Email: WP0 --f"veSe-091 C6 I, eOYYI
• Primary Owners : _ � nU���
Name(s): �i c�c, �— �►�, r ((�� nibu of Qy I a9,0`�
Mailing Address, C/S/Z: S Wh iSpe6i q fx es Way, Q V� r
Cell Phone: '_ Sig --Tq to 3 a l?
Email: eapprt-u-e..y-e oD Jrn O A' k, C c Y1n
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): bocvd 4 Send &(-I oW
Contractor Trade: PUois 00% '
Mailing Address, C/S/Z: 45 Iy)G n' Sfiree.+ QVUr SbU,,J r J/ i w-1
Cell Phone: Land Line: S18 193 — 6?0139
Email: My PWS 9 % Q Llallao. Covn
"Workers' Comp documentation must be submitted with th° a lication"
Contact Person for Compliance in regards to this project:
Cell Phone: Land Line:
Email:
Swimming Pool Packet Revised December 2020
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:May 1 s 2022 REVISED:
TOWN OF QUEENSSURY
BUILDING E.CODI~S
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