POOL-0416-2023 •
_ SWIMMING POOL Office Use Only_
PERMIT APPLICATION Permit#: Poi I--" 1
Town of Queensbury Permit Fee:$1 S r O;Invoice :
742 Bay Road,Queensbury,NY 12804 ,�
P:518-761-8256 www.queensbury.net Flood Zone? Y Reviewe By:d
Project Location: ce-gL upp' S>1.crw, 414—
Tax Map ID #: 3u1 , )? - 3 --.-Z Subdivision Name:
Proposed Install Date: ?b a/2 3
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: i
SIZE OF POOL: I
MANUFACTURER: .Vh �-c 0 h TOWN OrBui MG
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: 1k— 1 r
SIGNATURE: DATE: .2/3-/2
Swimming Pool Packet Revised July 2022
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s):
Mailing Address, C/S/Z: 8-k2 UPPcr- s/-cr'.- Avt v.-y /1/`( te.kol
Cell Phone: ( ) 3N2 737 v Land Line: (
Email: 3-At,.,44- 30 3e 5 :l,G aw,
• Primary Owner(s):
Narne(s): .Tos��k /-j-t,.,;I-)-- / CAz)c• /4-e� '
Mailing Address, C/S/Z: fir Z v Pl'c S key-r+-'c.,, ,L Q,,tz,.,.c A ci y oV'' 12 ro�(
Cell Phone:_( -o°L ) 3+-1't 3 7o Land Line: _( )
Email: -; j-?o e �rAk:1. co.-.
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: `,Te.s/. u ,
Cell Phone: S,£s01- ) 3s-4 7 3 7 Land Line: ( )
Email: Z Aew: J- .c) E ( , c,c
Swimming Pool Packet Revised March 2023
301.17-3-52 POOL-0416
Hewitt, Joshua -=: _
882 Sherman Ave
Above ground pool 24' round FILE COP
TOWN OF QUE :NSBURY ' �„a
BUILDING & C ES DEPT. .: : : - - - t) r 'l .,� L / C�
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