POOL-0627-2023 SWIMMING POOL Office Use Only
PERMIT AP C I ;Qu E 0 emit�k: f
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Town of eensbury �sC72 /
742 Bay Road,Queensbury,NY 12804 e t Fee:$ :Invoice#: pS
P:518-761-8256 www:queensbury:net OCT 0 4 2023flclo: Zone?•IN Reviewed By:
..J
TOWN OF QUEENSBURY
Project Location: 12 Berry PatchErlIPPM&CODES
Tax Map ID #.: �vf ( Z — t Subdivision Name:
Proposed Install Date:.ASAP
SWIMMING POOL INFORMATION.(please fill out completely):
TYPE: CHOOSE ONE:
ABOVE-GROUND UNHEATED
X IN-GROUND (inc. partially) _HEATED (pool cover heater, R-12 req'd.)
COST OF CONSTRUCTION:,'85.000
SIZE OF POOL: 1 6x4 1
MANUFACTURER: Thursday. Pools
MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY):
Steel/Vinyl Fiberglass X 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: Nadia Wright
SIGNATURE: ,.)CC DATE:
9/29/23
Swimming Pool Packet Revised March 2023
s ,
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant: Yook.,s
Name(s): i✓l1f/c..ES< s`
Mailing Address, C/S/Z: ) 1 D'e 4 L-Pi 11A u`', VAL)
Cell Phone: J) Land Line: ( S1$ ) 1�3 S2- (2_
Email: j e O Civess q-a_ IC a
• Primary Owner(s):
Name(s): 040 Uovs,c,k.
Mailing Address, C/S/Z: pmc,., L., 4rg,r4
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): OingeS
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: P
Cell Phone: ('VO ) S21 o Land Line: (
Email: )e4p C�Q('essf-02)SGoei1
Swimming Pool Packet Revised March 2023
MAP REFERENCE: \
MAP OF A SUBDIVISION 0
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RICNARD PH ERE
DATED NOYfAIBER ff,2002
LAST REVISED,NNE 23,2003
BY VAN DUSEN&SIEVES
LAND SURVEYORS _--...
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in leblecal 1:=0.114 Mr
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"'°'°M"M'"""""" Pierre J'. & Ruth H. Castonguay
Land Surveyors 1.1 a:WO -
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MEM OF'
189 Ravuand Road Queesnbury, New York 12804 "7,4=7.� ""MO - Town of queenebury, Warren County, Now York
1 MOVED HOUSE CASTONGUAY
618)782-8474 Now York L1o. No. 50136 NO. ,DATE DESCRIPTION I DVC No.02384-18