POOL-0283-2019TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5904 (518)761-8201
Community Development - Building & Codes (518) 761-8256
CERTIFICATE OFCOMP 1ANCE
Permit Number: POOL-0283-2019 Date Issued: Thursday, June 27, 2019
This is to certify that work requested to be done as shown by Permit Number POOL-0283-2019
has been completed.
Tax Map Number: 279.15-1-38
Location: 62 MUD POND RD
Owner: Concordia Schultz
Applicant: Jerry Ross
This structure may be occupied as a: Above ground pool
By Order of Town Board
TOWN OF QUEENSBURY
Issuance of this Certificate of Compliance DOES NOT relieve the
property owner of the responsibility for compliance with Site Plan,
Variance, or other issues and conditions as a result of approvals by the Director of Building&Code Enforcement
Planning Board or Zoning Board of Appeals.
TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5904 (518) 761-8201
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Community Development - Building & Codes (518) 761-8256
BUILDING PERMIT
Permit Number: POOL-0283-2019
Tax Map No: 279.15-1-3 8
Permission is hereby granted to: Jerry Ross
For property located at:62 MUD POND RD
In the Town of Queensbury,to construct or place at the above location in accordance with application together
with plot plans and other information hereto filed and approved and in compliance with the NYS Uniform
Building Codes and the Queensbury Zoning Ordinance
Type of Construction
Owner Name: Concordia Schultz Swimming Pool 0.00
Owner Address: 4024 Simkins AVE Total Value 0.00
North Port,FL 34286
Contractor or Builder's Name/Address Electrical Inspection Agency
Plans&Specifications
Above ground pool
125.00 PERMIT FEE PAID -THIS PERMIT EXPIRES: Wednesday, May 6, 2020
If a longer period is required,an application for an extension must be made to the code Enforcement Officer
of the Town of Queensbury before the expiration date.)
Dated at the Town of Queensbury; Tuesday, May 7, 2019
SIGNED BY:for the Town of Queensbury.
Director of Building&Code Enforcement
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SWIMMING POOL PERMIT APPLICATION Office Use Only
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Town of Queensbury VECEI1 L`/ E A 2
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Permit Fee:$ i 0e0: ; Invoice#: f 1
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TOWN OF OUEENSSURYDING& CODESProjectLocation: o l
Tax Map ID #:Z 7' , t5 -1 s) " Subdivision Name:
CONTACT INFORMATION:
Applicant:
Name(s): e‘Ccut teC
Mailing Address, C/S/Z: rY)uap( o, RC_\ C;v _C Lrlyt fit 1.) L-J
Cell Phone: ( 5 6 ) s.'J - ex..„(oO Land Line: (
Email: ee_te,)4'5ec`A fi Oc.4-°I 1$ @ C enai / „on,
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Primary Owners :
Name(s): eonCt ci' 1Gc
Mailing Address, C/S/Z: a_
Cell Phone: _( Land Line: _(
Email:
CJ Check if all work will be performed by homeowner only
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:
List all additional contractors on the back of this form
Contact Person for Building & Code Compliance: ( w
Cell Phone: _( c% () j 8 --76 o Land Lin : _(
Email: c_elesiesec iccedivj p3cflCUI Com
Swimming Pool Packet Revised February 2019
SWIMMING POOL INFORMATION:
CIRCLE ONE: BOVE- GROUND IN-GROUND
SIZE OF POOL: X /8 X 17' 8)'
MANUFACTURER: 1C?k C3..
MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY):
r
Steel/Vinyl Fiberglass Gunite Poured Concrete Other °'
pvc pc\ e*r 5 , de L31/4..)0.. 0,_s
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: S
SIGNATURE:0 DAT47)E:
Swimming Pool Packet
Revised February 2019