POOL-0616-2023 VSWIMMING POOL Office Use Only
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Permit#: P°"--
PERMIT APPLICATION
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Town of Queensbury (o5�o"Z
742 Bay Road,Queensbury,NY 12804 Permit Fee:$ f� Invoice#:
P:518-761-8256 www.queensbury.net Flood Zone? •)jj Reviewed By:C._JA \
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Project Location: 1 3ecri .
Tax Map ID if: 8781. h- I -a i Subdivision Name:
Proposed Install Date: tO/ 11 0 5L Q u
SWIMMING POOL INFORMATION (please fill out completely): SEP 623
20231
TYPE: CHOOSE ONE: u I Yam
ABOVE- GROUND UNHEATED +"kI `JiN i CL = a�
X' IN-GROUND (inc. partially) HEATED (pool cover heater, R-12 req'd.)
COST OF CONSTRUCTION: 1'-70, oco • ao
SIZE OF POOL: lb k �
MANUFACTURER: �c,'vl r Ze„.15 '1'�o� Csf\ik-cA, pv
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 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\ cLi
agree to the above:
PRINTNAME:
SIGNATURE: DATE: 1.
Swimming Pool Packet Revised March 2023
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant: .� II
Name(s): Lou k d C ,A(`,,lc
Mailing Addres r WS/Z: ?" cc es,� .
Cell Phone: (51�5 '1`(�- 1,a1-{ Land Line: ( )
Email: :Pk'1f \•l,_tJr✓w
• Pri ar Own r s :
Name(s): R6-c.c_kc .rui.
Mailing Address,.C S/Z: . cc (� („, .
Cell Phone: _( 5(x ) ��u -/(`azi Land Line: ( )
Email: Pt2k- SO .6i/
❑ Check if all work will be performed by property owner only
• Installer/Co tractor: (List(all additional contractor on the ba k o= his form)
Contact Name(s): G•v�,� (�oo\ o '1/4c
Contractor Trade: c,` \,,.54 10,_ ,
Mailing Address, C/S/Z: ?.B. -6c,k Lg ll C `; - „_ ?c. die /(
Cell Ph ne: _(,S(r Land Line: _( )
Email: 1(1 .,a, _ Z e'f �cU,c— .
**Workers' Comp documentation must a submitted with this application**
Contact Person DA.for Compliance in regards to this project: k,),„..e.A
Cell Phone: or ) c�c—�7t', Land Line: ( )
Email:
Swimming Pool Packet Revised March 2023
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ECOPY ATTENTI®N HOME OWNER
Please assure you are familiar with the Pool
Enclosure requirements specific)to your
pool.
s
You are required to meet all app s & hot tubs
regarding swimming pools, spa
at the time of inspection � ,
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TOWN OF QUEENSBURY
BUILDING & C.G i S EP I . A
Reviewed BY:
Date: f_ _O- Z
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TOWN OF QUEENSBURY
BUILDING DEPARTMENT
Based on our limited examination,compliance
with our comments shall not be construed as
icdicating The plans and specifications are in 73
full compliance with the Building Codes of
New York State. r"� O
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