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POOL-0181-2023 SWIMMING POOL Office Use only PERMIT APPLICATION Permit#: r`DB L-O I bI - Town of Queensbury 742"Bay Road,Queensbury,NY 12804 Permit Fee:I$ I : Invoice#: (0-0 1 P:518-761-8256 www.gueensburv.net Flood Zone? Reviewed By CAL I,I Project Location: Tax Map ID #: �;'} - - `Fj y _Subdivision Name: Proposed Install Date: 8 2 SWIMMING POOL INFORMATION (please fill out complet I JHEA �IC Eff��Bf E nn TYPE: CHAPR 2 0 2023 ABOVE- GROUND DC'' l�` 01=QUr. _EN,3_RURY IN-GROUND (inc. partially) '��" ' "~`"' ' poa7l`cover heater R-12 req d.) COST OF CONSTRUCTION' ' L ©. _ SIZE OF POOL: Is a! 3 L _ MANUFACTURER: J MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY): Steel/Vinyl Fiberglass Gunite Poured Concrete Other 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 state ment/descri"ption 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 2023 CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL a Applicant: Name(s): /' Mailing Address, C/S/Z: L' u cRd, Qu_tzAA6uw A& Cell Phone: 6—/9 ) q!44-,;?0 6 Land Line: Email: na Q-nvcd r& • Primary Owner(s): Name(s): 1.icei i"6 C LAW& I'Le2 Mailing Address, C/S/Z: 3) 0 hz.zd-nW �Zi C�A.e 12-01. sit! GL� . Cell Phone: _( S($ ) 3(al '1951 Land Line: _( ) Email: ❑ Check if all work will be performed by property owner only • Installer C ntractor: (List all additional contractors on the back of this form) Contact Name(s): \ Contractor Trade: < C Mailing Address, C/S/Z: U� Cell Phone: _(_) 31:�— 4_1 U6 Land Line: _( ) Email: �� _,P �>��r•, . c 4--, "Workers' Comp documentation must be submitted with this application" n / Contact Person for Compliance in regards to this project: 624d &Qy-dya)(e., Cell Phone: 51 ) 'JL14 - Land Line: � )� Email: 1uSfi-6r o.-mi-I_Q cCDnyn Swimming Pool Packet Revised March 2023