POOL-0192-2021 jSWIMMING POOL office Use only
PERMIT APPLICATION Permit#: aL-.— C �nZ,Z YL_J
Town ofCZecnsbury Permit Fee:$ Invoice
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.gueensbury.net Flood Zone? Y Reviewed By:
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Project Location: a.u-ee�n Pffvn � 2Z4
Tax Map ID#: Subdivision Name:
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30/. za --z-9 D 1
Proposed Install Date: - I
K6q FAR 0 5 2 E"'I
SWIMMING POOL INFORMATION: TOWN OF ?WEENSPUP �
BUILDIN ti=, ;: B;s
CHOOSE ONE: ABOVE- GROUND IN-GROUNDAac-
SIZE OF POOL: a` X � W - u��� 1 c
MANUFACTURER:
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 If, for any reason, the building permit application is withdrawn, 30% of the fee is retained by the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: I Z' d o�OZ DATE:
Swimming Pool Packet Revised December 2020
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(sJ7-D0-nkC,J,-) C -Th Q
Mailing Address, C/S/Z:
Cell Phone: -; d Te: �5 Ig --3 Z) --3.303
Email:.�Y'pal�rc�her� ��,CU• Lpl1�
• 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/Builder: (List all additional contractors on the back of this form)
Contact Name(s): � �� � -�� ��e. JD� r� 4e c)Wner
Contractor Trade: _C)y)gVaA(-
Mailing Address, C/S/Z:��y1� C-- -ee+ I C Ue-(- m, ln�. ! 8
Cell Phone:
Email:
"Workers' Comp documentation must be submitted with this application"
Contact Person for Compliance in regards to this project: JP canF
Cell Phone: . Land Line:
Email:
Swimming Pool Packet Revised December 2020
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1 FILE COPY I
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j� TOWN OF QUEENSBURY 1
3 BUILDING DEPARTMENT l
_ Based on our limited examination,compliance ►� J
t with our comments shall not be.construed as _ I!
indicating the plans and specifications are in
full compliance with the Building Codes of
New York State. '
_ r
TOW i�"OF QUEENSBUfY
- BUIL I O & CO ES i�To UN
Reviewed B : ►- _ _ _
Date: 17r
ATTENTION HOME OWNER P,
I
Please assure you are familiar with th� Pool
specific to your pool. n '
Enclosure requirements
livable codes "
i You are required to meet all app S
regarding swimming pools, spas & hot tubs I;V
at the time of inspection.
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