POOL-0272-2021 SWIMMING POOL office Use Only
PERMIT APPLICATION Permit#: P'0QL-ffi2-'2--Z02)
ay oa ,Queensbury,NY 12804 Permit Fee:$1�'p J :Invoice
P:518-761-8256 www.gueensbury.net Flood Zone? Y N Reviewed By:
Project Location: ��i 1 ch a rc i1. Lem e Lt eens 6c ' J a'jot+
Tax Map ID#: Subdivision Name:
ace). 1
Proposed Install Date:
SWIMMING POOL INFORMATION:
CHOOSE ONE: ABOVE- GROUND IN-GROUND
SIZE OF POOL: jt�lf ?j10
MANUFACTURER: L
Q E
MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY):
APR 2 6 2021
Steel/Vinyl CFibDerglassGunite Poured Concrete Other
i�,GU CODESRY
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 If,.for any reason, the building permit application is withdrawn, 30% of the fee is retained by the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�
I have read and agree to the above:
PRINT NAME: -Qi11�1`-�{',1� ��1�l
SIGNATURE: Q- Gam, DATE:
Swimming Pool Packet Revised December 2020
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Pride and Workmanship is Phone (518) 696-2b
Route 9N 12846 the Foundation of Out Homes
Lake Luzerne, N.Y. 6nANI] N HQMf6
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