POOL-0497-2021 SWIMMING POOL office Use only
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PERMIT APPLICATION Permit#: — L02J
Tv of Queen ry
742 Bay Road,Queensbury,NY .12804 . _ Permit Fee:$ .� :Invoice. c 13
P:518-761-8256 www.gueensbury.net Flood Zone? Y N Reviewed By:
Project Location: ':�2�5r i�j,� I�I�GGor,✓ G�+N Qac£ ,USl�G —Y lU `( ZISO
Tax Map ID#: Subdivision Name:
2a5, 19-5—&'3
Proposed Install Date: /
SWIMMING POOL INFORMATION:
CHOOSE ONE: ABOVE- GROUND -G UND
SIZE OF POOL:
MANUFACTURER: 4T. /"r,
MATERIALS USED-IN CONSTRUCTION,(CHECK ALL THAT.APPLY); D
&59WIVin Ju 3 p 2021l
'TO
�/N OF
BUILDING& eODBSRY .
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 If, for any reason, the building permit application is withdrawn, 30% of the fee is retained by the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 applicatior-date, 100% of the fee is'refained.
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:
SIGNATURE: DATE: &/ZZ5(/Z/
Swimming Pool Packet Revised December 2020
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•
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): D,i-
Mailing Address, C/S/Z: '3 S' fo fi /Ka L I✓ / eo
Cell Phone: Land Line: Col I
Email: W/NGFf.6 Gt
y %ge /9o1.- co/N
• Primary Owner(s):
Name(s): (1.v 1-- - .4;cri✓
Mailing Address, C/S/Z: _ Fok /2 c e ) /24soY
Cell Phone: Land Line: cc g- co a /0 f
Email: 57$ `ICS- 17_
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): -ti'/1 R S ne9-72- e
Contractor Trade: Poo 4-.9
Mailing Address, C/S/Z: ' 5 M 4 4 47- )14. ptis,4 � /yr '_''_
Cell Phone: Land Line: 67-_. 713 ,_z 1 z g
Email: bvc44 r ,u-(4 t D®ems Pc-cc
**Workers' Comp documentation must be submitted with this application**
Contact Person for Compliance in regards to this project: t--)u"1
Cell Phone: Land Line: 5 O,2-d- I
-- Email: _ •erg_ 50-
GJ i NGt- (�, rc y cl-f gee- 3 Zoe
Swimming Pool Packet Revised December 2020