POOL-0620-2022 ?: -. W SWIMMING POOL Office Use Only
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�" / - PERMIT APPLICATION Permit#:i( t 0(0'20 -Z0 22-.
Town ofQueensbury
742 Bay Road,Queensbury,NY 12804 Permit Fee:$ ; Invoice#: �V 1
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P:518-761-8256 www.queensbury.net Flood Zone? Y Reviewed By: 1 S
Project Location: 'Z '3,1 cc Pig i'
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Tax Map ID #: 29P - 16 " l -\ ii Subdivision Name:
Proposed Install Date: f 0(2-(-( / i&Z'Z.
SWIMMING POOL INFORMATION (please fill out completely):
TYPE: CHOOSE ONE:
ABOVE-GROUND )c UNHEATED
IN-GROUND (inc. partially) _HEATED-(pool-cover heater, R-12 req'd.)
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COST OF CONSTRUCTION: D/`'( 2O OCT o 5 2
• SIZE OF POOL: Vo?`; ' Tow
BUILD DIN &EENDEU�Y
Z
ES
MANUFACTURER:
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: J1-9"6--' - ^ .14 Ale- fp.�
SIGNATUR1-7
E: ,�t%i2 -- DATE: )0/3f Z°ZZ----
Swimming Pool Packet Revised July 2022
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): 41a-C -
Mailing Address, C/S/Z:
Cell Phone: L5 6 ) fS 3Z- J 2_Le Land Line: ( ---}
Email: ��-�!'t,.�-�e Z(4 vAAr.t t • CC,w
• Primary Owner(s):
Name(s):
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): Svi cvc, LS
Contractor Trade:
Mailing Address, C/S/Z: -3 O . CO a -/ 6L,,,,.•4-e_ (
Cell Phone: _( ) Land Line: ("AY ) 'Zu 7
Email:
**Workers' Comp documentation must be submitted with this application**
Contact Person for Compliance in regards to this project: ,
Cell Phone: (C(`tc ) `d S Land Line: ( )
-----
Email: f - 7 cf� v��e. ..�
Swimming Pool Packet Revised July 2022
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