POOL-0367-2022 t ;
SWIMMING POOL Office Use only
PERMIT APPLICATION Permit#: 0i�Yar�-- 2z22-
Town of Queen bus ry Permit Fee:$ �`4�
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742 Bay Road,Queensbury,NY 12804 �� ; Invoice#: u
P:518-761-8256 www.aueensbury.net Flood Zone? Y to Reviewed BN✓-1110
Project Location: �`f !`�G�W,a., /t�/� �J.��✓�
Tax Map ID #: SOS' `7— otz- Subdivision Name: 24rrl
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Proposed Install Date: `"
F -I�JN 14 2022
SWIMMING POOL INFORMATION: 1-(', +N OF QUEEN, I Y
/; 0JUILDING& CODES
CHOOSE ONE: _ABOVE-GROUND k IN-GROUND
UNHEATED 7k HEATED (pool cover heater, R-12 req'd)
SIZE OF POOL: // X-X
MANUFACTURER: Je
�✓�l/J�//�� ���
MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY):
Steel/Vinyl . o"' 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 If,for any reason,the building permit application is withdrawn, 30%of the fee is retained by the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.
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:
Swimming Pool Packet Revised March 2022
;T
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s):
Mailing Address, C/S/Z: 7el 4-1
Cell Phone: �' ) 3 '%�'��Z Land Line: .
Email:
"NJ f.001
• Primary Owner(s):
Name(s): </ do r �✓
Mailing Address, C/S/Z: 7 .0 f/ ;'A✓
Cell Phone:_ Land Line: _(A4.,iA
Email: �2 �✓r�r
❑ Check if all work will be performed by property owner only
Installer Contractor: (List all additional contractors on the back of this form)
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone:_( . / ) 31sy r.0 Land Line: _(-5-le )
Email: 'MxoeewlMalals` -1 API".
**Workers' Comp documentation must be submitted with this application**
Contact Person for Compliance in regards to this project:
Cell Phone:�_) Land Line:
Email:
Swimming Pool Packet Revised March 2022
D FCEaWE
JUN 14 2022
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TOM OF QUEENSBURY
TOWN OF QUEENSBURY IL-BRI CODES G
BUILDING DEPARTMENT &
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Enclosure requirements specfflc to you tpool.
ev611-1-11 16"e-41 You are required to meet all applicable codes
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308'.7-1-72* POOL-0367-2022
Raferty Jr. Thomas
74 Richmond Hill Dr
In ground heated pool