POOL-0507-2021 � i► SWIMMING POOL office Use only
#:P l�(JDL �G 7�Z�Z
PERMIT APPLI ( I , p�
Town of Queens Fee
p l-'$ /` .00 Invoice#:
NY 12804 e, .i "Z
742 Bay Road,Queensbury,
P:518-761-8256 www.gueensbury.net JUL 0 to one? Y Reviewed By
Project Location-3 7-OWN C'
Tax Map ID#:_ <3 f(a, l S Subdivision Name:
Proposed Install Date: 7 P 1<J {C)
SWIMMING POOL INFORMATION:
CHOOSE ONE: ,_ABOVE- GROUND _IN-GROUND;
SIZE OF POOL: Uc qk in
MANUFACTURER: ill n ?cx)IS
MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY):
Steel/Vinyl X 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 If, for any reason, the building permit application is withdrawn, 30% of the fee is retained by the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 they 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.
have read and agree to the above:
PRINT NAME: O��OrI
SIGNATURE: DATE:
Swimming Pool Packet Revised December 2020
1
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): =44a-; 3 l ' a0rn gcl WetAs>
Mailing Address,
Cell Phone: U57 A2 7 Land Line: )
Email: r,e rye_n hp "t /< C0M
• Primary Owner(s):
Name(s): cx,nLA J ""e.55 Sar)
Mailing Address, C/S/Z:�3L30 rA Ed nueets" Z.Bo
Cell Phone:_(s19' ) PQZ -4 — a`t -7J Land Line: _( �� i ) 9_g0 - S-Goq —L�11
Email:br-r*an.�j brg-rien 9(o QctfrarLZf. C6N7 rr 615ern L $7 61 9 r C-b
❑ 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):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _( )
Email:
**Workers' Comp documentation must be submitted with this application**
Contact Person for Compliance in regards to this project:
Cell Phone: �_) Land Line: �)
Email:
I
Swimming Pool Packet Revised December 2020
i
• Installer/Builder: (List all additional contractors on the back of this form)
Contact Name(s): 15 (0,n P_t P oe-,US
Contractor Trade: 196 7 t' -e-,o � 4vg , m b cr!3y
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line:
Email:
"Workers' Comp documentation must be submitted with this application"
is Installer/Builder: (List all additional contractors on the back of this form)
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line: _( )
Email:
"Workers' Comp documentation must be submitted with this application"
• Installer/Builder: (List all additional contractors on the back of this form)
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _( )
Email:
"Workers' Comp documentation must be submitted with this application"
Installer/Builder: (List all additional contractors on the back of this form)
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _( )
Email:
"Workers' Comp documentation must be submitted with this application"
Swimming Pool Packet Revised December 2020
TOWN OF QUEENSBURY
BUILDING & CODS DUEFT. FOLD � �
Reviewe By: —�
-- - --- _Date:
-- - --JUL--01-20'221--- - - ------ -
- - --
VN
TOWN OF QUEFNNSBURY
-------- r _ BUILDING-DE PA TMENT.__._ -_
4 Based on our limited examination,compliance
with our comments shall riot be construed as
-— — - indicating-the plans=and specs cations-are-in=—==
p full compliance with the Building Codes of
--- o= -----— --�-- --- - New York State.
-- - --- - - - --- - --- - - -
LUJ
-------- ------ ------ oc�Ste.- -- - - --- - - -----
--- -- --_- --- _--- _-__- -:Mo_ �"- - - - - - - -
T-ENTION-HOMEOWNER - - -
- --- =- - lease-assure=you-are fdMillar-wfth-the-Pool
Enclosure requirements specific to your pool.
- - — You-are-required-to-meet all appltcabe-codes - -- - - -
regarding swimming pools, spas hot tubs
- - --- - --- -- - -- ---- - -- - -
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