POOL-0276-2023 F
SWIMMING POOL Office Use only
f Permit#: �bQL-" O Z - 20 23
PERMIT APPLICATION
Town of Queensbury
742 Bay Road,Queensbury,NY 12804 Permit Fee:$ ti�� ; Invoice#: Cn151
P:518-761-8256 www.gueensbury.net Flood Zone? • Reviewed BytiA-C\
Project Location: 178 Farr Lane
Tax Map ID #: 2340029520140 Subdivision Name: Indian Ridge
Proposed Install Date: June 12 2003
SWIMMING POOL INFORMATION (please fill out completely):
TYPE: CHOOSE ONE:
X ABOVE-GROUND UNHEATED
IN-GROUND (inc. partially) _ HEATED (pool cover heater, R-12 req'd.)
COST OF CONSTRUCTION: 7,000
18 Feet
SIZE OF POOL: � � 44���
MANUFACTURER: Ad m i ra I �. Op
MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY): -- Z C30;�y�
'�...ti.. t, /
Steel/Vinyl X Fiberglass Gunite Poured Concrete Other
7
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: Diane Havern
SIGNATURE: DATE: S 7S` Z
Swimming Pool Packet Revised March 2023
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL -
• Applicant:
Name(s): Diane and Chris Havern
Mailing Address, C/S/Z: 178 Farr Lane Queensbury NY 12804
Cell Phone: ( )518 796 7995 Land Line: �)
Email:cdhavern@gmail.com
• Primary Owner(s):
Name(s): Diane and Chris Havern
Mailing Address, C/S/Z: 178 Farr Lane Queensbury NY 12804
Cell Phone: _( )518 796 7995 Land Line: _( )
Email:cdhavern@gmail.com
❑ Check if all work will be performed by property owner only
• Installer Cont ctor: (List all additional contractors on the back of this for
Contact Name(s): g LLC
Contractor Trade:
Mailing Address, C/S/Z: 0.. w izon
Cell Phone: _( ) Land Line:
Email:
"Workers' Comp documentation must be submitted with this application"
Contact Person for Compliance in regards to this project: Diane Havern
Cell Phone: ( )5187967995 Land Line:
Email:cdhavern@gmail.com
Swimming Pool Packet Revised March 2023
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ATTENTION HOME OWNER � ���1�`� 2 5 20G3
ATTEN II gg
Please assure you are familiar with the.Pool i Tc';k�rN t ,
Enclosure requirements specific to your pool. j F3UILDil,a<;
You are required to meet all applicable codes
regarding swimming pools, spas & hot tubs
at the time of inspection. 10 ft WIDE
NO CLEAR ZONE
ALONG REAR LOT LINES
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o TOWN OF QUEENSBURY
0) coov' ( `ram "�` 0,58 acres I BUILDING DEPARTMENT
N 'U ;_ W Based on our limited examination,compliance
Z . , t� d with our comments shall not be construed as
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indicating the plans and s eci ications are in
'� M full compliance with the Building Codes of
( { �' New York State.
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