POOL-0350-2022 SWIMMING POOL office Use only
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PERMIT APPLICATION Permit#: -a
Town of Queensbury
742 Bay Road,Queensbury,NY 12804 Permit Fee:$ �;Invoice#: Z +
P:518-761-8256 www.gueensbury.net Flood Zone? Y __16 Reviewed By: CAA
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Project Location: 4-"
Tax Map ID M ��- t 46 Subdivision Name:
D
Proposed Install Date: 01 JUN 0 6 2022
TOWN Or OUEENSBURY
SWIMMING POOL INFORMATION: BUILDING 3:CODES
CHOOSE ONE: /ABOVE-GROUND _IN-GROUND
UNHEATED _HEATED (p of cover heater, R-12 req'd)
SIZE OF POOL: _29
/
MANUFACTURER: S
St/ e -e2 To / cc
MATERIALS USED IN CO-NVST U TION (CHECK ALL THAT APPLY):
Steel/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 If, for any reason, the building permit application is withdrawn, 30%of the fee is retained by the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 fhe abov
PRINT NAME: �J/�ez
SIGNATURE: . DATE: IYr
Swimming Pool Pack t� Revised March 2022
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• A lica
Name(s): C
Mailing Address, C/S/Z: C Y we--,
Cell Phone: —r r ) 'S Land Line:
Email: `f
• Primary Owners : .
Name(s):
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _( )
Email:
Zr/Check if all work will be performed b property owner only
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• Installer/Contractor: (List all additional contractors on the back of this form)
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line: _( )
Email:
"Workers' Comp documentation must be submitted with this application"
Contact Person for Compliance in regards to this project: el. C4 AA&
Cell Phone: Land Line: �)
Email:
Swimming Pool Packet Revised March 2022
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