POOL-0438-2022 S1fV MMlltlG POOL Office Use only
'_��� PER 1' APPLICAT ON '1 Permit#:
Town afQueensbury 9 3 n��� i Permit Fee:$ 1 V.U� voice
742 Bay Road,Queensbu y,NY 12110. JUL
P:518-761-8256 www. ueensbu .net ~6~ Flood Zone? Y N /eviewed BC1WN OE Q1iEI; ,SB RYY
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Project Location: 1/\) SIC � i�li5
Tax Map ID #: �� - Subdivision Name:
Proposed Install Date: s\ 2DL2�
SWIMMING POOL INFORMATION: /�
CHOOSE ONE: _ABOVE-GROUND V -GROUND
UNHEATED HEATED (pool cover heater, R-12 re 'd
SIZE OF POOL: 1 s
MANUFACTURER:I
MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY):
Steel/Vinyl d/ 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 If, for any reason,the building permit application is withdrawn, 30%of the fee is retained by the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 to the above:
PRINT NAME: k , Kw
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SIGNATURE: �__� DATE: —[ -Z�--
Swimming Pool Packet Revised March 2022
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CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): ►`l 11�1�� L0�1�
Mailing Address, C/S/Z: \ ,\N s F uL Ch Quc(_ralst)�ni At
Cell Phone: (SIR) )Irl 1 - 7S23 kafcl-ti re:
Email: r`^ 1 V►ooL�l 2_1E MID cyiy•
• Primary Owner(s):
Name(s): -
Mailing Address, C/S/Z: A pevE
Cell Phone:_( ) Land Line: _( )
Email:
❑ 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): ODDS U ��j
Contractor Trade: —'
Mailing Address C/S/Z:
C44 W one:_( ) -1�3 - Iq 2-tJ Land Line: _( )
Email: rn w-- hl �.Gt3yvt
"Workers' Comp documenta ion must be submitted with this application"
Contact Person or Compliance in regards to this project: ��P.v1 a g�\Kuyi
Cell Phone: ) CT')- Mo Land Line: 0ib
Email: rhU ffiL_rS l&S P� A-VAdo .CaV\A
Swimming Pool Packet Revised March 2022
ATTENTION
HOME OWNER �.,�,
J U L 13 2022 Please assure you are familiar with the Pool
T OVVN' Or QUEENSBURY Enclosure requirements specific to your pool.
BUILDI.P1G CODES You are required to meet all appiicabigcodes
--�— - �-- regarding swimming pools, $ hpt tubs
at the time of Inspection, SPa3
TOWN E QUEENSBURY
BUILDING & CO ES EPT.
Reviewers B o�,
OWN OF QUEENSBUR
`�- I UILDING DEPARTMEN —C
�B on ur limited examination,c liance
ur c mments shall not be co ` '
the plans and specificati ns ajefull comp)ante with the Building Code
New York State. 1
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C73
301.15-1-25 POOL-0438-2022
Matt Woodcock
9 Wings Falls Court
Inground Heated Swimming Pool