POOL-0086-2021 SWIMMING POOL office Use only
PERMIT APPLICATION Permit#: %(It—M5(o — 102
742NRoaueensbury,NY 12804 Permit Fee:$ Invoice#: _
P:518-761-8256 Flood Zone? Y Reviewed B
Project Location:Tax Map Map ID#: Subdivision Name:
30\-A-2-2z-
Proposed Install Date:
SWIMMING POOL INFORMATION: DECEOVE
CHOOSE ONE: ABOVE-GROUND IN-GROUND FEB 2 6 2021
SIZE OF POOL: y�(��$ TOWN OF OUEENSBURy
BUILDING ODES
MANUFACTURER:
MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY):
C�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 If, for any reason, the building permit application is withdrawn, 30% of the fee is retained by the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 to the above:
PRINT NAME: *_1 �
SIGNATURE: �� -�-'S DATE: Z.ln -L
Swimming Pool Packet Revised December 2020
4
:Y
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicants
Name(s): VG
Mailing Address, C/S/Z: vA I-ogm
Cell Phone: Land Line:
Email: -����\SCs•-��5® c�ma:� . Lp,rv�
Primary Owner(s):
Name(s): ?,-,\kP;E
Mailing Address, C/S/Z: E�cC (\'\c. �� •
Cell Phone: Land Line: 1 Sid - •-�01 loc(g5
Email: 310 G -`1 Q
Check if all work will be performed by property owner only
Installer/Builder: (List all additional contractors on the bac of this form)
Contact Name(s): �� Vw�tis Az--- (�Sz .e-n�, 10QScf�S
Contractor Trade: per\
Mailing Address, C/S/Z: 7ql
Cell Phone: Land Line:
Email:
"Workers' Comp documentation must be submitted with this application"
Contact Person for Compliance in regards to this project: � G
Cell Phone: Land Line:
Email:
Swimming Pool Packet Revised December 2020
MAP REFERENCE: TOWN F QUEENSBURY nn
THE GROVE OVE SUBDIVISION BUILDI G DEPARTMENT Y �, -0 l!DATED
NOVEMOER G. .2 0 ®� D
VE
LAST REVISED MARCH T ES Based on our limit d examination,compliance
S LAND SDL.URYEYOR5 TLLGS with our commen shall not be construed as
indicating the pla s and spec'fications are in 21 FEB 2 6 20?1
full compliance ith the Building Codes of
New York State.
TO N D NG&CODES OF Y
503°22'00'E
225.0
NO-CUT / LC
ZONE 5
ATTENTION HOME OWNER
lease assure you are familiar with the Pool
nclosure requirements specific to your pool. �� /
ou are required to meet all applicable codes ;o WN OF QUEESgURY
egarding swimming pools, spas & hot tubs I0 ILDING &
23 z 79.03' `I WOODTrRAMC CO 11_,s PIT.
t the time of inspection. \ HOWE
CRUSHED eviewe :
! FROM AN ACTUAL FIELD SURVEY.EBY CERTIFY THAT THIS MAP WAS PREPARED \ �Ur \ STONE
THIS CERTIFICATION 5MALL RUN ONLY TO THE PERSTHEIRONS DRIVEFOR VR10M THE SURELY WAS PREPARED.AND ON AGENCY
\ �'� Date: �k
BEHALF TO THE TITLE COMPANY.HEREON.
GOVERNMENTAL AGCHCY
AND LENDING INSTITUTION NOT UNITED TRANSFERABLE
INSTITUTIONS
O ARE NOT TRANSFERABLE TO ADDITIONAL
� PISTfLU110N5 OR SU55EOL1ENT OWNERS. \ / � Vy��ti A
CERTMM TOj JAMES R.SMART t LEE A.SMART
MfT MORTGAGE CORPORATION.IT'S SUCCESSORS AND/OR ASSIGNS 4�
UNITED GENERALtT7 44Sl1RANCC COMPANYCERTIFIED
y
MATTHEYI'G.STEELS.Ll5.NY5 50135 1"C,
DATED,OCTOBER 7.2003�C�"U u°�`;• - - -- -__ _
i ... UTILITIES
301.14-2-22 POOL-0086-2021
Dean, Robert
59 McEchron Dr
In ground pool
Date, , 2003
I an S` }•� �'"'�;a�' ,' .,o;";' Map of a Survey made for Scale 1'=30'
i & •mod
j Steves JAMES R. & LEE A. SMART S-1
Land Surveyors � SHEET,OF,
169 Havlland Road Queeasbury, New York 12804 ,�, srt�,.,,°.°-„A, u0 Town of Queeasbury, Warren County, New York SMART
j (518) 792-8474 New York lAc. No. 50135 NO. DATE DESCRIPTION DWG.NO.55415-22