application SWIMMING POOL PERMIT APPLICATION office use only
Permit#:
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SEP 11 2017 Permit Fee:$ (� 00; Invoice#:
742 Bay Road,Queensbury, NY 12804
Notes:
P: 518-761-8256 www.gueensbury.net
Project Location: 225-
Tax Map ID #: Subdivision Name: A)A_
CONTACT INFORMATION:
• Applicant:
Name(s): 01 k-
orlt� C rcJ
Mailing Address, C/S/Z:
Cell Phone: 61t ) '2I/ —y ' Land Line:
Email: �
• Primary Owner(s):
Name(s): (A'01c l 4Ax1)(_
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _( )
Email:
• Installer/Builder: j
1,
Business Name: det rm" eA A4 .+' (14k
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _( )
Email:
Contact Person for Buildinp, & Code Compliance:
Cell Phone: _( ) j rl —/a�6 Land Line: _( )
Email:
Town of Queensbury Building&Code Enforcement Revised February 2017
SWIMMING POOL INFORMATION:
CIRCLE ONE: �{ ABOVE- GROUND QN-:GROUND
SIZE OF POOL: 15 �..
MANUFACTURER: Z
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.
PRINT NAME: ( .�✓
SIGNATURE: 1 DATE:
Town of Queensbury Building&Code Enforcement Revised February 2017