POOL-0093-2022 li
SWIMMING POOL office Use only
PERMIT APPLICATION Permit#: )P°OL-
Town ofQueensbmy Permit Fee:$ % Invoice#: Z{673
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.gueensbury.net Flood Zone? Y CD Reviewed B EA)_
or
Project Location:
Tax Map ID #: o�F�. I oZ - -aLf Subdivision Name: � I' ��' 1
Proposed Install Date: il r6
SWIMMING POOL INFORMATION:
CHOOSE ONE: _ABOVE-GROUND _)t/IN-GROUND
_22UNHEATED _HEATED (pool cover heater, R-12 req'd)
SIZE OF POOL: \°J
MANUFACTURER: I cLn1 bg 'ar 1 1v Ls
�- y -%-MATERIALS USED IN CONSTRUCTION (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 If, for any reason, the building permit application is withdrawn, 30% of the fee is retained by the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 to the above:
PRINT NAME:
SIGNATURE: v DATE: 'q'
Swimming Pool Packet Revised November 2021
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant: /-,, /}��
Name(s): �1 D � h I' �Q.� {1� 'i /' Ce�l r
Mailing Address, C/S/Z: -� 6
Cell Phone: S ) - � _. Jve - e: /;t 1
Email: G" C6
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• Primary Owner(s):
Name(s):
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line: _( )
Email:
❑ Check if all work will be performed by property owner only
• Installer/Contractor: (List II dditional contractors on the back of this form)
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z: ( 1
Cell Phone:_( _) Land Line:
Email: W
**Wor ers' Comp documentation must be submitted with this application**
Contact Person for Compliance in regards to this project: C/V"L�f N
Cell Phone: (5 ) y `( ( rj5 Land Line: I ) `7 932 a��-
Email: G\/PL'e� Ni)/)I 0LAG- (-r,
Swimming Pool Packet Revised November 2021
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ATTENTIOR jjQME OWNER
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