POOL-0223-2022 174Bay
SWIMMING POOL Office Use Only
PERMIT APPLICATION Permit#:Roa lueensbury,NY 12804 Permit Fee:$ Invoice. :
P:518-761-8256 www.aueensbury.net Flood Zone? Y �Ne�vlewed Byda"'`
Project Location: brcb�6Q\ $\A)
Tax Map ID#: Subdivision Name: D EC LP R VIE
Proposed Install Date: APR 2 8 �'J?
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OF QUEE-A'SBURY
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�DIN G 8. GOpE
SWIMMING POOL INFORMATION:
CHOOSE ONE: ABOVE-GROUND0-1
IN-GROUND
SIZE OF POOL: \�X J I X all LC�go 1
MANUFACTURER: a �n\
MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY):
Steel/Vin Fiberglass Gunite Poured Concrete Other
ADDITIONAL IMPORTANT INFORMATION: E�SgUR
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1. Any changes to the approved plans prior to or during construction ill r IN`etkt brfiitt I 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 If,for any reason,the building permit application is withdrawn, 30%of the fee is retained by the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 NAML V �
SIGNATURE: L/
DATE:
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Swimming Pool Packet Revised December 2020
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s):
Mailing AAress, /S/Z:
Cell Phone: Land Line:
Email: a\,;NWM�('��
• 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 Names)-�% �Rs"x
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: Land Line: n _�al cS S
Email: J
"Workers' Comp documentation must be submitted with this application"
Contact Person for Compliance in regards to this project: K01
Cell Phone: Land Line:
Email:
Swimming Pool Packet Revised December 2020
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.75 POOL-0223-2022
290 Shaelee & Alec Fuller
3 Brookfield Run 001
In ground swimming P -