POOL-0250-2023 SWIMMING POOL office Use only
— � '� `� ,, �,� ermit#:
PERMIT APP�.ICi4TJON' '
Town of Queensbu zy I I Permit Fee:$ f 50, ?Invoice#: �'!/�
742 Bay Road,Queensbury,NY 12804 � �AY y �'23 � '
'� _ Flood Zone.
P:518-761-8256 www.gueensburV.net ? • Reviewed B
BUILDING &,
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Project Location: 516 Luzerne RdP_n....v_,�__
Tax Map 1D #: 308.6-2`1 Subdivision Name:
Proposed Install Date: ,July 2023
SWIMMING POOL INFORMATION (please fill out completely):
TYPE: CHOOSE ONE:
ABOVE- GROUND _ UNHEATED
X IN-GROUND (Inc. partially) X HEATED (pool cover heater, R-12 req'd.)
COST OF CONSTRUCTION: 55000
SIZE OF'POOL: 16x32
MANUFACTURER: Pools Plus
MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY):
Steel/Vinyl X 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 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' [ 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: Holly Irlon and Shane Donaldson
SIGNATURE: DATE: 5/1 3/23
Swimming Pool Packet Revised March 2023
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): Holly Irion &Shane Donaldson
Mailing Address, C/S/Z: 516 Luzerne Rd., Queensbury, NY 12804
Cell Phone: ( )518-260-6686 Land Line: _�)518-791--3669
Email:shane.m.donaldson@gmail.com AND hollyirion@gmail.com
• Primary Owner(s):
Name(s): Holly Irion &Shane Donaldson
Mailing Address, C/S/Z: 516 Luzerne Rd., Queensbury, NY 12804
Cell Phone: _( )518-260-6686 Land Line: _( )518-791-3669
Email:shane.m.donaldson@gmail.com AND hollyirion@gmail.com
❑ 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): Dave Barlow at Pools Plus
Contractor Trade: Pool Installer(Pools Plus)
Mailing Address, C/S/Z: 45 Main St., Queensbury, NY 12804
Cell Phone: _( )518-955-1180 Land Line: _( )518-793-2929
Email:mypoolsplus@yahoo.com
"Workers' Comp documentation must be submitted with this application"
Contact Person for Compliance in regards to this project: Dave Barlow at Pools Plus
Cell Phone: _J )518-955-1180 Land Line: _�)518-793-2929
E m a i I:mypoolsplus@yahoo.com
Swimming Pool Packet Revised March 2023
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