application Z f SWIMMING POOL PERMIT APPLICATION Office Use Only
Permit It: 0:kil1 07D1'5 2-®1
Town of Queensbury Permit Fee:$ 12- J ;Invoice#:1541-
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net Notes.
Project Location: \ , s t kUV c O br
Tax MapID#: 210 . - 1 - 5 y 0-S
t
� �J Subdivision Name:
CONTACT INFORMATION:
• Applicar�
Name(s): '� Q ��►--
Mailing Address, C/ : �- t�"�L Wcue) Y-
Cell Phone: ( ) `a oO-1'9 -Cp Land Line: (5 a ) ` ''2_ (ea(
O
Email: Co ? Jr S�C0)5hrt Cs e
• PrimaOwner(s/:
Name(s): S/Z:
V
Mailing Address, ----- r S1u
iao on or,
Cell Phone: ( J 1'2 ) d '-� `r Land Line: _( S7 ) 52.- (d( 6
Email:
❑ Check if all work will be performed by homeowner only
• Installer/Builder. orkers' Comp ocumentation must be submitted with this application
Contact Name(s): Nc'ti ►-s� pa zA S
Contractor Trade: &
Mailing Address, C/S/Z: I( �I Itl c+ cd - ���� ( (S ��, (2
Cell Phone: _( �l ) T61 , - ® `3 Land Line: _(
Email:
**List all additional contractors on the back of this form
Contact Person for Building & CodeComplia ,AK t Th. p®Ac
Cell Phone:
Email:
(
' ' L -�
MAY 17 2019 a,
TOWN OF QUEENSBURY
BUILDING&CODES
Swimming Pool Packet Revised February 2019
{
SWIMMING POOL INFORMATION:
CIRCLE ONE: ABOVE- GROUND IN-GROUND
SIZE OF POOL: Vdy 17
MANUFACTURER:
MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY):
Steel/Vinyl l.."/ 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:
SIGNATURE: _�.�......_.,- DATE:
o r
Swimming Pool Packet Revised February 2019