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SWIMMING POOL PERMIT APPLICATION Office Use Only
-- -._.. Permit#: 4,OUL- O)0-2SS M.
Town of Qyeensbury J5)
(� 2 �/]
L E C L5 / 'ermit Fee:$12S• D; Invoice#: 1
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net L_________IE
O 1 2019 jJotes:
TOWN OE QUEENSBURY
Project Location: 1 , r / br BUILDING& CODES
Tax Map ID #: �' (� ?� ( S Subdivision Name:
CONTACT INFORMATION:
• Applicant:
Name(s): —r1,1orna-s . k i ►rt1
Mailing Address, C/S/Z: 1 S iZe rrl fir; ve_ Q ueehs 6(.&rt../ N l.( (2 e0 ti-
Cell Phone: (S18 ) S S - 41 aS Land Line: ( )
Email: Share- -t c 7 Q, n ti c a..p. fr. co rrl
• Primary Owner(s):
Name(s): 'T horna.s E. 4C i nct
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _( )
Email:
❑ Check if all work will be performed by homeowner only
• Installer/Builder: Workers' Comp documentation must be submitted with this application
Contact Name(s): Sera 's ►�-z-we;r.ci foots L L C / ► I-kvt.et 71.-t"ca{"-;
Contractor Trade: Peot -T-ns►rttLc,"
Mailing Address, C/S/Z: 300 1mc cfti u�4-e_ 44 1 F,ra-EA, 4 N't (ig2S
Cell Phone: _( vs ) 30, - 01-s-9 Land Line: ( 'OS ) ?NO- * 12.70
Email: 5{rtt44Lj eo,,.t6L 61) ,r,2o, , vx-e-^
**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
SWIMMING POOL INFORMATION:
CIRCLE ONE: ABOVE- GROUND IN-GROUND
SIZE OF POOL: ( L X 3 3 MANUFACTURER: 3-- p'^"f-�-^4,� `4)&I S
MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY):
Steel/Vinyl x 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: d-S &. k ,YL
SIGNATURE: \ DATE: $ 41 i 9
Swimming Pool Packet Revised February 2019