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2024-0189
` SWIMMING POOL Office Use Only �_ PERMITIAPPLICATION +�;;' ,i - ©a� J d /g� Town ofQueensburyff" [ +mit#: 1 c' �oLI rO,353a 742 Bay Road,Queensbury,NY 12804 } , 1 Permit Fee.$ 5 , Invoice#. If P:518-761-8256 www.queensbury.net APR 25 2'i=� i I 1 i �Fl od Zone? Y Reviewed By:/. TOWN ;_F . ._ : . ,' Project Location: 3 G Ai2R4 SO AI 24). Tax Map ID #: 30,2_,, II - I —64 Subdivision Name: Proposed Install Date: b b,--/ SWIMMING POOL INFORMATION (please fill out completely): TYPE: CHOOSE ONE: ABOVE-GROUND ►/ UNHEATED / IN-GROUND (inc. partially) _ HEATED (pool cover heater, R-12 req'd.) COST OF CONSTRUCTION: '5'30i 10D 14/.5 pe,cat ,,b SIZE OF POOL: - I x A g , MANUFACTURER: PODL-S MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY): Steel/Vinyl / Fiberglass Gunite Poured Concrete Other 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: t4A EI< sc aL I. Pdi I SIGNATURE: / _c DATE: l J3DkV/ Swimming Pool Packet Revised March 2023 CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL • Applicant: Name(s): Mei< scei 1 e4I Mailing Address, C/S/Z: ,3 6A2P_1S6r( 2l 62/3v / goL( Cell Phone: ( 5"/$ ) -79 -76159 Land Line: ( ) Email: MA2KCcr'.9I /G>>(c' (, fI_ 4Gom • Primary Owner(s): Name(s): 5Am e_ As iqo v•e_ Mailing Address, C/S/Z: Cell Phone: _( ) Land Line: _( Email: ❑ 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): PooLS PLUS bAvib aniaLOLJ Contractor Trade: Pool_ , nAST/3L/1-n(AS Mailing Address, C/S/Z: ) c j1?! sr &r3y Al V/ / ago," Cell Phone: _( ) Land Line: _( / ) '7q 3 - ga19. Email: mkpon(PL gpJ.vS r' `/raHoo, Cava **Workers' Comp documentation must be submitted with this application** o r epu e ei i3ei2 i/ N,-S 0t/ Fi L Contact Person for Compliance in regards to this project: Ny0 811 raid)cJ Cell Phone: ( ) Land Line: ( 5/ S ) 7q3 - 9a9 Email: M t/Pooi_S Pi•-uS %/AKoo, co/1 Swimming Pool Packet Revised March 2023 € ' o _4 (15 o k' kA LAJ M N 0 �. tD cn � Fi p . ISCL ® 0� 01nio EF c C 7—® rn �rrt -- ... , -Y Lo v 0 PA NJ cc 00 �CL� cn CDM 0 -C Pt1 e% 5 ® CD ca us n r 5 CL vt U� rn i Q . (p.0 zCL L