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POOL-0198-2021
SWIMMING POOL office Use Only Permit#: 1 ©�1— � � V 20 2-1 PERMIT APPLICATION Tinvn tfCLlectistxu� Permit Fee: $ ; Invoice#: 2551Q3 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.gueensbury.net Flood Zone? Y N Reviewed By: Project Location:gG Tax Map ID#: Subdivision Name: 30a_-1-1-(do �1 Proposed Install Date-7akkkA Z-C)ZJ D ECEOVE. SWIMMING POOL INFORMATION: CHOOSE ONE: ABOVE- GROUND IN-GROUN 26 1 SIZE OF POOL:0V 0A UP 4 * 3 z�� TOWN OF QUEENSLURY BUILDING &CODES MANUFACTURER: �� MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY): Steel/Vin Fiberglass Gunite Poured Concrete Other ADDITIONAL IMPORTANT INFORMATION: 1. Any changes to the approved plans prior to or during construction will require the submittal of amended plans, additional reviews and re-approval. 2. If, for any reason, the building permit application is withdrawn, 30% of the fee is retained by the Town of Queensbury. After 1 year from the initial application date, 100% of the fee is retained. 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: VkJ; 55� .S SIGNATURE: DATE: Li Swimming Pool Packet Revised December 2020 CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL Applicant: Name(s): ale;tea, Gc,-QS Mailing Address, C/S/Z: Qq (L.�'c �o ` 11 C)S �Jq 1280� Cell Phone: Land Line: GiQ, 3 cG I - z,-1 :?, ZL4 Cc-) Emai1:dC&C" 107- -7 S) L4C V%Z� .L®-VYN • Primary Owner(s): Name(s): 9.SSD.-C3 -,,(; n Mailing Address, C/S/Z: qq Q� �Y`= ��'1 Vk Cell Phone: Land Line: S Ioo_ Email:��l ,1OZ1�(��C 1 nd el cjc� � Check if all work will be performed by property owner only • Installer/Builder: (List all additional contractors on the back of this form) Contact Name(s): QC)0�S 9W5 Contractor Trade: ?,04�.-r,S\pAI� . � - Mailing Address, C/S/Z: (4 5 �O.i ,n S-# , QS6,_, q 1 2gvy Cell Phone: Land Line: Gie�~ j 3_ Zcl Zq Email: "Workers' Comp documentation must be submitted with this application" Contact Person for Compliance in regards to this project: O Lu rI Gp,C1 a uJ 005IS RUS) Cell Phone: Land Line: ZS I g_--Iq 3 _ Z g Z 9 Email: W t\!.W, CY OCAS QLuS. CO-V ` Swimming Pool Packet Revised December 2020