POOL-0234-2022 /
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swim
PERMIT AM
742 Bay Road,Queensboqy,NY 12804
P:S10-761'@2S6
Ll dI KNA rQ
Project on:
Tax Map ID #: Subd ���� e: I J
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ProposedInstall Date:SWIMMING POOL INFORMATION:
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CHOOSE ����E: ABOVE- �
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U��HEATE[� ��~HE/QE]D (pool cover heate � A-12 raq'd)
SIZE OFPOOL: 001 �
MANUFACTURER:
MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPR1. |
Steel/Vinyl Fiberglass Gunite PouredConorete []ther______
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ADDITI ONAL IMPORTANT INFORMATION:
l. 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 If, for any reason, the building permit application is withdrawn, 30 e fee is retained by the
Town of[}ueensbury. After l year from the initial application date| 10O% of the fee isretained.
Declaration: I acknowledge -- _n_--_'_' activities s all be commenced
I certify that the application, plans and supporting materials are a true and!complete statement/clescription of
the work proposed, that all work will be performed in accordance with the NY3 Building Codes, local building
|axvo and ordinances and in conformance with local zoning regulations. 11 acknowledge that | have read the
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application and plot plan requirements and |, or my agents will obtain a certificate of compliance before use
mf the pool.
I have read and agree to the bove
SIGNATURE: DATE:
Swimming Pool Packet ' ' � xAi eumvmxzozz
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CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): KV ) D`A
Mailing Address, C/S/Z: 'Z 4 &MW,A
Cell Phone: Pq'1-yj_) 6 -K'LIq Land lLine:
t; ( )
Email: ; d0 c,�)r c
• Primary Owner(s): _
Name(s): Q K)) p
Mailing Address, C/S/Z: tr &J vn 1-t r'ly
Cell Phone: _( 1 /�- Land Line: _( )
Email: cinq 6n0 Din 104hAel") I UM
❑ 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): r ,S -5A C�
Contractor Trade: AD,
Mailing Address, C/S/Z: S Goo 1f,gAr. Qutt�d-<GvfZA! NY I V61
Cell Phone: _( ) Land Line: _(_S 1 1)c 1
Email:
**Workers' Comp documentation must be submitted with this application**
Contact Person for Compliance in regards to this project:
Cell Phone: Land Line: 07 — i r4 C-1
Email: j
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Swimming Pool Packet Revised March 2022
TOWN OF QUEENSBUR`l
BUILDING & CODES DEPT.
Reviewed B
. tea �.-. -- "Zr �.•�
TOWN OF QUEENSBURY ?
BUILDING DEPARTMENT
Based on our limited examination,compliance i
with our comments shall not be construed as ','f�
indicating the plans and specifications are in
full compliance with the Building Codes of
New York State.
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ATTENTION HOME OWNER
? Please assure you are familiar with the (Pool `• rt 1.
Enclosure requirements spedflc to your pool.
You are required to meet Il all applicable codes
regarding swimming pools, spas & hot tubs
at the time of inspection.
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