POOL-0432-2023 Mk. elk
SWIMMING POOL Office Use only
PERMIT APPLICATION Permit#: ? " — 0 3Z• 2ZL3
Town of Queensbury 22
742 Bay Road,Queensbury,NY 12804 Permit Fee:$ lir"Db ;Invoice#: J j
P:518-761-8256 www.queensburv.net Flood Zone?•fri Reviewed By:�—r
Project Location: / eeh 1 /e.,ine.
Tax Map ID #: ?O,i ( / — 3 t/ Subdivision Name:
Proposed Install Date: 7/21-/c:W
SWIMMING POOL INFORMATION (please fill out completely):
TYPE: CHOOSE ONE:
ABOVE-GROUND UNHEATED
y IN-GROUND (inc. partially) X HEATED (pool cover heater, R-12 req'd.)
COST OF CONSTRUCTION: c0 1°®
SIZE OF POOL: c2i Xs 116 4
2023
MANUFACTURER: per,',(,( I fC6ic TOWN/ ; D
0 BUILD rzUEENBB
MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY): 1NG& CODESRY
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 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:
ot
PRINT NAME: 1/ t i L.L Ntiot.'ejNa•-‘
SIGNATURE: 2./ I DATE: 0,43
Swimming Pool Packet Revised March 2023
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant: //.1� n r
Name(s): tOrl
Mailing Address, C/S/Z: por 1-44e _) Queen t,614-r1 1/0/ Jc (P,4Y
Cell Phone: ( ) 636- 7S9 Land Line: ( SIB' ) '3 3 `I-.5..l-'Lf/
Email: @p
• Primary Owner(s):
Name(s): 7 k- a- 1'6)re-y h q ✓i>i S civi
Mailing Address, C/S/Z: I k Q,A ePr .s Lane 3 (Q14 PPV1J 61 (1) Y l d�'Dy
Cell Phone: _( s i8' ) 6 3 6 - 97s--7 Land Line: _( s)dam) �3)Z/- s-1-1f/
Email: , Lit do)irk sit Son e - c D�
❑ 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): Nav,. ga riat, 10f'O1 s Pith
Contractor Trade:
Mailing Address, C/S/Z: Y /11 a,h <-7-,r,Q�ti� (Pi,kPPv2J Lvi.") �Y , cee)
Cell Phone: _( 51? ) `1.v.�- 1 i '() Land Line: _( ,51( ) 7q - dug
Email: :ry. pcf3 ,I P/uS yq koo.4 (of,
**Workers' Comp documentation must be submitted with this application**
Contact Person for Compliance in regards to this project: 2` c.� ���+.` �, •
•
Cell Phone: ( Sig ) 1,.3 6 ` q7c' Land Line: (
Email: it W.c[aareocv,e__ r , - Cry
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Swimming Pool Packet Revised March 2023
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