2024-0331 "' SWIMMING POOL Office Use Only
1 °f f APPLICATION Permit#: 2024— 0 1
Town of Queensbury Permit Fee: 150
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensburv.net Invoice#: 1_
VIP
Flood Zone? TYPE:
PE: ; N
Project Location: l 110 $U.(Ind- 1--\1 h Or Reviewed By: t
Tax Map ID#: 3O' T 12- 1 -36 Subdivision Name: E(,,I,(V* V-iA e
Proposed Install Date: 71 11 -
SWIMMING POOL INFORMATION (please fill out completely):
TYPE: CHOOSE ONE:
❑ABOVE-GROUND gi UNHEATED
1 IN-GROUND (inc. partially) C HEATED (pool cover heater, R-12 req'd.)
fSWIMSPA D 1Et1 �a
COST OF CONSTRUCTION: 4 4Q, 000 [ JJ2Q2L
1
SIZE OF POOL: 20 k "I 0
` TOWN OF QUEENSBURY
MANUFACTURER: N BUILDING&CODES
MATERIALS USED IN CONSTRUCTION] (CHECK ALL THAT APPLY):
Steel/Vinyl X 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 pplication, 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 C?des, local building laws and ordinances and in conformance
with local zoning regulations. I a ((knowledge that I have read the application and plot plan
requirements and I, or my agents,411 obtain a certificate of compliance before use of the pool.
I have read and agree to the above: �l
PRINT NAME: ,i 1 l GC Ic lin y\
SIGNATURE: DATE: / e_, 1
I
Swimming Pool Packet Revised May 2024
CONTACT INFORMATION: PLEASE RINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): >e c f\� ,k ifv'CC1
Mailing Address, C S/Z: ) {o . i (v\c Or Q
Cell Phone: S} - - O LI IO Land Line:
Email: )4 \ C }\fJr O.@ \{C'r taat). CCA,y
• Primary Owner(s):
Name(s): \!'€'
Mailing Address,C/S/Z:
Cell Phone: I Land Line:
Email:
El Check if all work will be pe ormed 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 documektation must be submitted with this application**
Contact Person for Compliance in regards to this project: }C C' *-y �,i 1C{V\
Cell Phone: .� _1LIL- 1 V C Land Line:
Email: 1 1rJ Wvc r C \(iVixl . co Ito
Swimming Pool Packet Revised May 2024
TOWN OF QUEENSBURY
BUILDING DEPARTMENT
Based on our limited examination,compliance
with our comments shall not be construed as
indicating the plans and specifications are in
full compliance with the Building Codes of FILE
New York State. COPY
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r ,gamr ATTENTION HOME OW '
Please assure you are familiar with thh. Pcol `,
Enclosure requirements specific to y• b.l 8 '� TOWN OF QUEENSBURY 1 BUILDING&CODES
You are required to meet all appli. s ,,�'�
regarding swimming pools,
at the ti of insspapection.
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308.12-1-36 2024-0331
Stockman, Jerry
116 Burnt Hills Drive
In ground unheated pool 20 x 40