POOL-0464-2023 , 4
SWIMMING POOL office Use only
Permit#: Coo L`U L)6j_"Z.t;Z-3
PERMIT APPLICATION
Town of queensbury Permit Fee:$ b•OD Invoice#: U
742 Bay Road,Queensbury,NY 12804 f it orW
iz_ 7 Y Reviewed By
P:518-761-8256 v✓ww.gueensburV.net (,/ iS U
JUL 2 7 >�
Project Location: ^T )(� �PiX VVW -�- --
�lJSt?il�{y t
(JaOj=S
Tax Map ID #:5a�� oo �.��^�— ` Subdivision Name LA
Proposed Install Date:
SWIMMING POOL INFORMATION (please fill out completely):
TYPE:: CHOOSE ONE:
V/ ABOVE-GROUND UNHEATED
_IN-GROUND (inc. partially) _ HEATED (pool cover heater, R-12 req'd,)
COST OF CONSTRUCTION: � r
ii u
SIZE OF POOL: _1_� X �S�A
MANUFACTURER:
MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY):
Steel/Vinyl. _V/ Fiberglass Gunite Poured Concrete Other S
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: t')'1 ano-
SIGNATURE: ,o DATE:
Swimming Pool Packet Revised July 2022
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): . 1 C3�Y1 ► I I S
Mailing Address, C/S/Z: q0q 1 oe i EC
Cell Phon SI ) OIL - Land Line: ( J1� ) ��a- �5(�
Email: 1 o-n"co % i C
• Primary Owner(s): 1 _
Name(s): V " �� L 1 �S RuuP\FSCLJ
Mailing Address, C/S/Z: i Ahf iz—
Cell Phone:_ Land Line: _(��) 4 — S
Email:
❑ Check if all work will be performed by property owner only
Installer/Contractor: (List all 1ad)ditio al contractors on a back of this form)
Contact Name(s): Rr�;c r��r �y(�S_C� �p�/1 t bn ��pAS
Contractor Trade:
Mailing Address, C/S/Z: C)LA Q
Cell Phone:_( ) Land Line: _( Ic
Email:
"Workers' Comp documentation must be submitted with this application"
Contact Person for Compliance in regards to this project: lG-na
Cell Phone: (51 Q ) - q g� 3 Land Line: _ (�i� ) --1 0D — LA ^1 C)
Email: 10 o,-V i Vlo i l
Swimming Pool Packet Revised July 2022
D E C E `Vj E ATTENTION HOME OWNER
i Please assure you are familiar with the Pool
JUL 2 7c to your pool.
�-
Enclosure requirements specift • `?• -: ,.
TO ,e �, FILE PY You are required to meet all applicable codes
WN OF Q1Qf,f: ", �y o _ ,,, s &hot tubs
BUILDIN"Y regarding swimming pools, spa '
`` ``' at the time of inspection.
TOWN OF QUEENSBURY
0 !�� BUILDING DEPARTMENT
• Based on our limited examination, compliance
�j with our comments shall not be construed as
C 0 � indicating the plans and specifications are in
?' full compliance with the Building Codes of
New York State.
4
. o � ,Y y TOWN OF QUEENSBURY ,
`� • E(VI BUILDING & CO ES EPT.
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FILE COPY 304.13-1-1 POOL-0464-2023
Diana Gillis
499 Dix Avenue
above ground pool