POOL-0456-2021 ...?f,t1-
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/ / SWIMMING POOL Office Use Only
1,,,?. ..„.!..,4' Permit#: FbC3/1--- — elka) • 202-1
PERMIT APPLICATION
:,i •,:1 PerilliFeeK'S' 14:),'''•\'',.;*InVoite#•::',M)f5tir:',:•,,r.,-,
742 Bay Bead;itneeniliiiiilkilY.'1281iii-1 ' '-' ' .," 1 f it'-.-P • ,Q 1•••c••3 't t T•'A•— -- ,-t, ' ' ' ' .''' ,—,,, ,,,,-, - •,-...1. ,o..,.,,,
P:518-761-8256 www.queensbury.net Flood Zone? Y N Reviewed,By:
Location
Project
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Tax Map ID#: Subdivision Name: ''''A' r-•.:4 ''.J'' ..;
5-2•340 0 278.-(-43 , - ,: , L- CLEGY. E''' '' '
Proposed Install Date:
,._•(,.f.,:.•_fi!;:j-ilii'411161.; ''
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SWIMMING POOL INFORMATION: . oWtv:bP origa766 ''
.,..)3UILD,ING & CODE ,
......,..—....,•:_-.......
CHOOSE ONE: ABOVE-GROUND cIf1ROUND
SIZE OF POOL: I 1r X 3 ,
v',m-,.;: , -.., ,,- -, q y 41 .9) N 1 Oh eqi 5,C1 C; i3 V:1i Al DVV i 1 i A:::Yr2,:41:: .
MANUFACTURER: Edilituy4-
/ ,C'i nf. .,491.:0,1E§:k;', :,f-,,‘O
MATERIALS USED IN CONSTRUCTION (CHECK ALL APPLY):'--- - ' - ' -'-- '' -' ' . ' .
- S7-t;TiVinyl Fiberglass Gunite Poured Concrete 'Other- '-4)%jol))ain
ADDITIONAL, IMPORTANT INFORMATION:, • . . .., .: .:: .. . -, _ ', . . --. :
1 'Anyibangeito.lhe.aPprOvediilaiii,'PhoribideduriiigJeonitrUttion,miili eetkiiie'.th'6,itibritiittl Of
amended plans, additional reviews and re-approval. . . .
.. . ., -
2. lf, for any reason,,the:building pep-pita pplication,js withdrawn,,,,ai0P/p,of(Og'fic0 liPPOPC1)3tY-Ae., -")
Town of QueenSbury. After 1 year from the initial application date, 100.%Tot tile fee is retained,4 :..,:••
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Declaration: I acknowledge no construction activities shall be commenceckprior to issuance of a validip,errnit.
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l certify that the application, plans and supporting materials are a true and complefe:-State'rnerifidektiptidn'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
apphcation and plot plan requirements and I, or my agents,will:obtain a certificate of compliance before use
of the pool.
A
I have read and agree to the above:
- PRINT NAME: V-(AA) VA PUS C°F6P't
, A
SIGNATURE: QL1-1-41-- iiii r Yi 4 I)1
DATE:
_ .
Swirrrnir4.3 i';>c:1 Pa ckei Res4iiiti '2ii2i)
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CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN:tMaNIL
• ApOlicanti
Name(s): -DCZ.1)-IN\ plisa:Fs(4
Mailing Address, C/S/Z: (03) kq-C. 64
61€:- 1-(
Cell Phone: c/o Land Line:,,
Email:
,ao,a joc,Itfpi irt.IttX). Czann
• Primary Owner(s):
Name(s): 5'etirne,
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email: :)
Check if all work will be performed by property owner only
• Installer/Builder: (List all additional contractors.pn the back:of this form),
Contact Name(s): iw\
Contractor Trade: CI 1-006-€4 ,03:70/4,
Mailing Address, C/S/Z: 3. 1.1 Q.6tly La"0., 5-4140\)) ) ,( se-co.5-
Cell Phone: Land Line:
516t-, Q3 -
Irv\ cl roAre,tx4e,rf°DI imar I • , ,
,*!Workers",:Comp documentation,.must bessubmitted with this,application*!
Contact Person for coniolianceiiiiiegato§tvithiptojecti ; , -
Cell Land Lin :u'' " 0 "
• Email: 51r-26o-1'131 .
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Swimming Pool Packet • Revised December 2020
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