POOL-0593-2023 SWIMMING POOL Office Use Only
` Permit it - O' -
PERMIT APPLICATION
Town of Qgccnsbury
742 Bay Road,Queensbury,NY 12804 Permit Fee:$ c�� ;Invoice it:
P:518-761-8256 www.queensbury.net Flood Zone? • Reviewed By:.('1n
Project Location: 64 John Clendon Road
Tax Map ID #: 523400295.15-2-5 Subdivision Name:
Proposed Install Date: 10/15/23 _•. t � �r=1
FS; 19 2O2SWIMMING
POOL INFORMATION (please fill out completely):
TYPE: CHOOSE ONE TOWN OF QUEENSBURY
BUILDING 8:CODES
_ABOVE-GROUND UNHEATED
X IN-GROUND (inc. partially) HEATED (pool cover heater, R-12 req'd.)
COST OF CONSTRUCTION: $40,000
SIZE OF POOL: 16'X32'
MANUFACTURER: Platinum Pools (Pools Plus)
MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY):
Steel/Vinyl X Fiberglass Gunite Poured Concrete X 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: Timothy Ciampa
SIGNATURE: ' DATE:
9/19/23
Swimming Pool Packet Revised March 2023
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): Timothy Ciampa
Mailing Address, C/S/Z: 64 John Clendon Road
Cell Phone: ( )518-956-1466 Land Line: ( )518-956-1466
Email:ciampatj@gmail.com
• Primary Owner(s):
Name(s): Timothy and Kristie Ciampa
Mailing Address, C/S/Z: 64 John Clendon Road
Cell Phone: _(518 )956-1466 Land Line: (518 )956-1466
Email:ciampatj@gmail.com
❑ 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): David Barlow
Contractor Trade: Pool Contractor
Mailing Address,C/S/Z: 45 Main St, Queensbury, NY 12804
Cell Phone: (518 )793-2929 Land Line: (518 )793-2929
Email:mypooispius@yahoo.com
**Workers' Comp documentation must be submitted with this application**
Contact Person for Compliance in regards to this project: Timothy Ciampa
Cell Phone: ( )518-956-1466 Land Line: ( )
Email:ciampatj@gmail.com
Revised March 2023
Swimming Pool Packet
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