application SWIMMING POOL PERMIT APPLICATION Office Use Only
Permit#:Pp8t---012 2- 20
Town of Queensbury
Permit Fee:$ 125 Invoice#: ZteS
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net Notes:
Project Location: C I O�ver\ PVQ QUV)St3LA l'-(1 ) 1y V 1 tic'
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Tax Map ID#: Subdivision Name:
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CONTACT INFORMATION: MAR 12 2019 L.;
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• Applicant: 1aBid2Y
(j �---�- TOWN OF '
Name(s): &Inc I"h i I Q 1 N 'C'
Mailing Address, C/S/Z: �l )�;Q.() A'ie Le C to .NiV /�,Za 4
Cell Phone: ( 5i�s ) ..3S/ -,lids 1I-La4cLLine: ( 5i )� '4 3 e„
Email: , ,r r�tj I 3 ryK`,l , C'a�;r r� � � r 1 -fe r r- i yrct oc 3 c yl
• Primary Owner(s): `
Name(s-FrPht 1i p `Terry +- Qr d c , I e-.r�'
Mailing Address, C/S/Z: it (Di,.e n )\v CA Loons rlt m i SAC L)
Cell Phone: _(51 i� ) 4� `-f _J401 j " L-a d Line: _( ;I ) i4(16' h,
Email: C,t fef r iri it i..;; C Y1C 1 C.Z14) ph ) r --er r1( € y .0 cn -
❑ Check if all work will be performed by homeowner only
• Installer/Builder: Workers' Comp documentation must be submitted with this application
Contact Name(s): G/os7o-�t Gv�c��ti.ss /��t.yslz -2�.a�,i
Contractor Trade:
Mailing Address, C/S/Z: c css' .�.d"i A (��,,,,��,� C Avy /ZY
Cell Phone:_( Sig ) 32:L Land Line: _( ja' ) '>3 —
Email:
**List all additional contractors on the back of this form
JContact Person for Building & Code Compliance: Dew S , �� ,cc Se.Cil1C'f
Cell Phone: ( )3 ) 5 0 2)3 Land Line: (
Email: S cllrOcun 3i 6:Td. irct ,Cc-VI
Swimming Pool Packet Revised February 2019
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• Installer/Builder: Workers' Comp documentation must be submitted with this application
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Contact Name(s): ( j c-cir! .t Oil 0,1\`�\ -‘ C4 ack eC'A 1r1C‘ LLC
Contractor Trade:
MailingAddress, C/S/Z: ci -1 OACc.k A Huck--)co c-Lt( AiV raz '34
Cell Phone:_( ) Land Line: _( 5 I ` ) 1-{c3C1.- . '3 7
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:
• 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
- W
SWIMMING POOL INFORMATION:
CIRCLE ONE: \ ABOVE- GROUND IN-GROUND
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SIZE OF POOL: n-` - COO IA
MANUFACTURER: %rra,zrd,,,:t "0 _> �d
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 agree to the above:
PRINT NAME: FLi .4,, :'c tc t : t"r cz` 1' �f;.
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SIGNATURE. , L' , < r x L �,., i ;> r r, , �`a, DATE: --,
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Swimming Pool Packet Revised February 2019