POOL-0267-2023 1 1 i
SWIMMING POOL Office Use Only
PERMIT APPLICATION
Permit#: POB 1..." '2-b`;--2 e2?j
Town of Queensbury
742 Bay Road,Queensbury,NY 12804 Permit Fee:$ 150 ;Invoice#: t68
P:518-761-8256 www.queensbury.net Flood Zone? Y Reviewed By / '/"-
Project Location:14 bC&ira -3-2o 1)1 . j C-AAttio ii .j I no q-
Tax Map ID #:J2J 400 col , up- (-4g Subdivision Name: Le-lilt-nick -e(61-Cx--CS
Proposed Install Date: 51 )23
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: 4 top
SIZE OF POOL: I .. ;)..t4 Jam'
MANUFACTURER: I r14--e.Ne--
MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY):
Steel/Vinyl K 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: rr> '"r'Pl l� /Ep/, f/
SIGNATURE: ec� 642..1 DATE: n iq I3
Swimming Pool Packet Revised July 2022
,
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): f),e.e 1 Vv .
Mailing Address, C/S/Z: QtAif,-t bi,vi.41-- l"1tvt,
Cell Phone: ( 51`6 ) �°t l -05510 Land Line: (512 ) -19. _ g ,
Email: r-,9 re p to .r'da.dr-uu'w e--• C.,o,r -1
• Primary Owner(s):
Name(s): eels,
v� _
Mailing Address, C/S/Z: 14 -. 1n ILL.
Cell Phone:_( l g ) -i t 1 - oS'C Land Line: _( cJl% ) — lei a -4 7..5
Email: ruip-e pi 1 rd(IAA r jC
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):
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: A $ ([n.
_o:Cell Phone: ( ) Land Line: ( )
Email:
Swimming Pool Packet Revised July 2022
5/17/23, 10:34 AM Town of Queensbury Interactive Mapper
TOWN OF QUEENSBURY
BUILDING DEPARTMENT
Interactive Mapper Based onour limited examination,complianceruea
Town Of Queensbury,
with our comments shalt not be construed as
indicati•1g the plans and s ecifications are in
full com liana e i
,
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FID 16142 �
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rNEWNUMBE�`Ri 291 5.10-:1-48
IOWNERI PATRICK PEIN
OWNERMAIL3 74 Sara-Jeri Dr
OWNERMAIL4 Qfaeensbury, NY
ZIPCODE 112804 =
GISACRES 10.706486
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295.10-1-48 POOL-0267-2023
Pepin, Patrick
74 Sara-Jen Dr
Above ground pool
hftps://gbygis.queensbury.net/webapp/default.html?pid=295.10-1-48 1/2
MAP REFERENCE:
LEHLAND PARK
BY D.L. DICKINSON ASSOCIATES
FILED NOVEMBER 3, 1987
CABINET A SLIDE 128
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30,760 sq. ft.
I HEREBY CERTIFY THAT THIS MAP WAS PREPARED
FROM AN ACTUAL FIELD SURVEY.
THIS CERTIFICATION SHALL RUN ONLY TO THE PERSONS
191.66 FOR WHOM THE SURVEY WAS PREPARED, AND ON THEIR
_ BEHALF TO THE TITLE COMPANY, GOVERNMENTAL AGENCY
N851010"W AND LENDING INSTITUTION LISTED HEREON.
CERTIFICATIONS ARE NOT TRANSFERABLE TO ADDITIONAL
INSTITUTIONS OR SUBSEQUENT OWNERS.
CERTIFIED V. PATRICK J. PEPIN
TRUSTCO B I`y1%TIONAL ASSOCIATION.
IT'S SUC ASSIGNS
UNITES NSURANCE COMPANY
C.
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CERTIFIED BY:
MA S, NYS 50135
DATED:June Z 199W.
I.R.F. s IRON ROD FOUND e LANS3 ¢
Date: June 2, 1998
,„w�„mK„ a n,m�ro.,.� Scale 1"=30'
V '�n u S' }� EE,m,E, ,. Map of a Survey made for
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1164 LIMY M911041®N/C0.MOAlS fM SIC '
Land Surveyors, LLC
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SHEET 1 OF 1
37 Chester Street Glens Falls, New York 12801 ro ,�„�o 'N` Town of Qneensbury, Warren County, New York 1 6-5-915 BANK NAME IN CERT.
LEHLAND LOT 14
518) 792-8474 New York lac. No. 50135 NO. DATE DESCRIP77ON DWG. N0. 89423-14