POOL-0498-2021 ` SWIMMING POOL office Use only
Permit#:
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IFF PERMIT APPLICATION
Town of Queensbury.
Permit Fee:$/*-Op Invoice#: 3q I(P
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.gueensbury.net Flood Zone? Y N Reviewed By:
Project Location: j jwiv eam®r -a 9A
Tax Map ID#: Subdivision Name: D E C E OW IE
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Proposed Install Date: JUN 30 !"""j
t •3 % TOWN OF QUEENSBURY
BUILDING& CODES
SWIMMING POOL INFORMATION: ---- -�--�_ mM_
CHOOSE ONE: ABOVE-GROUND IN-GROUND
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SIZE OF POOL: /1 x 7
MANUFACTURER: 1,Vj1'71r'jAj' l6.o �- S
MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY):
E
l/Vinyl 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 If, for any reason, the building permit application is withdrawn, 30% of the fee is retained by the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: 4oq.-.'KL /,_>a1J LJ d
SIGNATURE: % DATE: 26 Z
Swimming Pool Packet Revised December 2020
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): A oUlAjc '
Mailing Address, C/S/Z: El
Cell Phone: Land Line: ` �` My
Email: �; � Siva, `���• �i���. / ��� ��/ •�5��,�r�`
• Primary Owner(sl:
Name(s): 5, A;%I r A Aj,��'r�/'�
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
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): T VP JV OL'41z"yO
Contractor Trade: Pooh-- 0V)2-'v
Mailing Address, C/S/Z: 6—,� GCS
Cell Phone: Land Line: ��
Email: C0/A4
"Workers' Comp documentation must be submitted with this application"
Contact Person for Compliance in regards to this project:
Cell Phone: Land Line: y� V
Email:
Swimming Pool Packet Revised December 2020
TOWN OF QUEENSBURY
BUILDI NG & COD S PT.
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ATTENTION HOME TOWN OF QUEENSBURY ME OWNER
R70.00, BUILDING DEPARTMENT
PIA83e assure you are t'8miti:��
BS 58°09'30 Based on our Limited examination,comnlian^e E with the p,,?t
C78,06, with our comments shall not he construed as �osure requirements sp,c;ifir_ to vour phi,
Indicating the plans and s.2cifications are: in You are required to meet aN a
full compliance with the �uilding Codes of Wwabie
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