application SWIMMING POOL PERMIT APPLICATION Office Use Only
Permit#: YOU. D
Town of Queens+ury Permit Fee: $ IZ� ; Invoice#: 1(2 `J7
742 Bay Road,Queensbury,NY 12804
P: 518-761-8256 www.queensbury.net Notes:
Project Location: 34 Masters Common North
Tax Map ID #: Subdivision Name: a .._ --•_s r,.�
CONTACT INFORMATION: \ JUN 2 2019
• Applicant: ;OWN OF QUEENSSEIRY
Name(s): Robert and Kristin Ricciardelli BUILDING&CO® s
Mailing Address, C/S/Z: 34 Masters Common North, Queensbury, NY 12804
Cell Phone: ( 518 ) 307-1544Kristin's cellLand Line: ( ) Bob's Cell (518) 791-3699
Email: stina12804@gmail.com (Kristin); kristyrick@gmail.com (Bob)
• Primary Owner(s):
Name(s): Robert and Kristin Ricciardelli
Mailing Address, C/S/Z: 34 Masters Common North, Queensbury, NY 12804
Cell Phone: ( 518-)307-1544 Land Line: _(
Email: stina12804@gmail.com (Kristin); kristyrick@gmail.com (Bob)
❑ Check if all work will be performed by homeowner only
• Installer/Builder: Workers' Comp documentation must be submitted with this application
Contact Name(s): Brett VanDerwarker Northern PoolScapes
Contractor Trade: Pool installer
Mailing Address, C/S/Z: PO Box 791, Glens Falls, NY 12801
Cell Phone: ( 518 ) 222-6517 Land Line: _(
Email: bvpoolscapes@gmail.com
**List all additional contractors on the back of this form
Contact Person for Building & Code Compliance:
Cell Phone: ( ) Land Line: (
Email:
Swimming Pool Packet Revised February 2019
• Installer/Builder: Workers' Comp documentation must be submitted with this application
Contact Name(s): Terry Colvin
Contractor Trade: Colvin Electric
Mailing Address, C/S/Z: 2 Hobbs Ln, Fort Edward, NY 12828
Cell Phone: _( ) Land Line: (519 ) 761-3079
Email: colvinelectricl@yahoo.com
• Installer/Builder: Workers' Comp documentation must be submitted with this application
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _( )
Email:
• Installer/Builder: Workers' Comp documentation must be submitted with this application
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _( )
Email:
• Installer/Builder: Workers' Comp documentation must be submitted with this application
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _( )
Email:
• Installer/Builder: Workers' Comp documentation must be submitted with this application
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _( )
Email:
Swimming Pool Packet Revised February 2019
SWIMMING POOL INFORMATION:
CIRCLE ONE: ABOVE- GROUND IN-GROUND
SIZE OF POOL: 18' x 36'
MANUFACTURER: Latham International
MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY):
Steel/Vinyl V 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 agree to the above:
PRINT NAME: Kristin N. Ricciardelli
SIGNATURE: DATE: 06/08/2016
Swimming Pool Packet Revised February 2019