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POOL-0166-2022 SWIMMING POOL Office Use Only PERMIT APPLICATION Permit#: Town of Queensbury Permit Fee:$ ;Invoice#:41/0 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.queensbury.net Flood Zone? Y N Reviewed By: Project Location: 4/6 /4 ,cd S1" Tax Map ID #: Subdivision Name: Proposed Install Date: AA 1` 19 do gA APR 0 6 2022 jj SWIMMING POOL INFORMATION: TOWN OF QUCFMSBURY BUILDIN0 &CODES CHOOSE ONE: ABOVE-GROUND _IN-GROUND 9C._UNHEATED _HEATED (pool cover heater, R-12 req'd) SIZE OF POOL: a' Ft u N GI MANUFACTURER: ` V'1C MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY): Steel/Vinyl K 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 If, for any reason, the building permit application is withdrawn, 30% of the fee is retained by the Town of Queensbury.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: Pc) le r t C ( r ee,,J SIGNATURE: DATE: Swimming Pool Packet Revised November 2021 Ir CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL • Applicant: Name(s): A, to e rt QL.1 s b L r q N.y. /2 Svo Mailing Address, C/S/Z: 4/31— 6/6uJ,z rr/ sr (.71 u Cell Phone: (,Si ) a-3Q- 976? Land Line: ( ) Email: • Primary Owner(s): Name(s): 1`C d h r f C. a Mailing Address, C/S/Z: '{ hie; cue3rd h ti r /lfd y_ Cell Phone:_( ) Tgz - q7 rbb9 Land Line: _( ) Email: ❑ 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): PrG-Pe 5S 1ci7cti p001 In&1c. ) )e{s LLC. Contractor Trade: Pool Z: i?s l I-e.r5 Mailing Address, C/S/Z: 465 I-kp (11 41 Rcl It G) J-OJv So x Cell Phone:_( ) Land Line: _( 5 8 ) -J LI - ) ((Qq Email: **Workers' Comp documentation must be submitted with this application** Contact Person for Compliance in re ards to this project: Cell Phone: (61 ) as-4 7 6 Land Line: ( ) Email: P) eer,O3 (T Y*rk c t r0 Swimming Pool Packet Revised November 2021 `-'JG G o �5r. p1c. DW o_ __ cl ` pi L CM a t \-\ � G© < z- . 1-- tp NrJ a) r o LL iel 1,1� a ATTENTION HOME OWNER `� °o Please assure you are familiar with the Pool Enclosure requirements specific to your pool. a, V?J You are required to meet all applicable codes regarding swimming pools, spas & hot tubs at the time of Inspection. TOWN OF QUEENSBURY BUILDING & CO, E EPT. ReviewE By: Qtk-tom(, Date: ZZ TOWN OF QUEENSBURY BUILDING DEPARTMENT Based on our limited examination,compliance with our comments shall not be construed as indicating the plans and specifications are in full compliance with the Building Codes of New York State.