POOL-0356-2022 SWIMMING POOL office Use only
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PERMIT AP 4
Town of Queensbury D U/
742 Bay Road,Queensbury,NY 12804 �O� r i F e:$ ll��� b;Invoice#: J"
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P:518-761-8256 www.gueensbury.net BUN o Q 20 , FI o e? Y � Reviewed By�
Project Location:5q We � c ry way 04 UEIrN.�`i 3lJ `i(
Tax Map ID#: 30.7 - S -3 5 Subdivision Name:
Proposed Install Date: 5u IV lo2J--
SWIMMING POOL INFORMATION:
CHOOSE ONE: _ABOVE-GROUND X IN-GROUND
UNHEATED )-HEATED (pool cover heater, R-12 req'd)
SIZE OF POOL: LS,000 541on S
MANUFACTURER:
MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY):
Steel/Vinyl / Fiberglass Gunite Poured Concrete 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 If, for any reason, the building permit application is withdrawn, 30% of the fee is retained by the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
t to the above:
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PRINT NAME: /�J I C-14 , , I i n.
SIGNATURE: DATE:
Swimming Pool Packet Revised March 2022
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CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s):&.r 1 L C.-,)i r%,,
Mailing Address, C/S/Z: S q Va esAen:x ki wy aveR_r-56,(1� I a-yo 4
Cell Phone: (SI Y ) `7 9 G -4�-) Land Line: �)
Email: I-c-r—(s INO • M.oCJ P-
• Primary Owner(s):
Name(s): N Cdt_
Mailing Address, C/S/Z: S9 UeS�6e,-(y We y Q,)c emL-2v(-r 1),go
Cell Phone:_(S V ) 7 9 $? a Land Line: _( )
Email: C0-r-1; i^C' a_S @ e;,ram. cc,r�
❑ Check if all work will be performed by property owner only
• Installer/Contractor: (List all additional contractors on the back of this form)
Contact Name(s): Poo I S Pl u S
Contractor Trade:
Mailing Address, C/S/Z: Q,ee,s �t� Mevj YorK
Cell Phone:_( ) Land Line: _(S 1�_) _1`13 -M19
"W ro kers' Comp documentation must be submitted with this application"
Contact Person for Compliance in regards to this project:
Cell Phone:�_) Land Line: � )
Email:
Swimming Pool Packet Revised March 2022
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JUN 0 8 2022
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TOWN OF OIJ ENS13URY
BUILDII`�� (;ODES
LANDS OF NIAGARA MOHAWK POWER CORPORATION
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II g 125,00'
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PROPOSED
IHOUSE
45.00'I 1 25.00'
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p°'COOS, � S03°52'05"E
100.00,
WESTBERRY WAY a
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( y ; POOL-0366-2022
I j 308.7-1-35
Nick Gariino
59 Westbe r Way
In-Ground