application s--- - /'
SWIMMING POOL PERMIT APPLICATION Office Use Only
,-----1' Permit#: ?COL_ D aj2�- 2-011
Town of CQpecnsbnry 5— ;
Permit Fee:$ Z invoice#:
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net Notes:
Project Location: '7 12_ t' P - 5/1,,41,4 v ii'
Tax Map ID#: 3 1. ( g-( - 15 Subdivision Name: 6e✓A& ne----
' 3 - /a 6 7
CONTACT INFORMATION:
• Applicant:
Name(s): / 1f ciOc i-- l
Mailing Address, C/S/Z: 'l ( L If it I'&2_- c1,E ,►„. •,, A—' q(..4 ), A/ 72_ !
Cell Phone: ( S%k) S 1 f-qt 60 Land Line: ( )
Email: - -Rodal 66-6 - C''1
• Primary Owner(s):
Name(s): 5441 e' /Yr A--vt
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line: _( )
Email:
4,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: 7/1 % ii -. /&- 72 _—
Cell Phone: _( SCE') 57,-f/C? Land Line: _( )
Email: + (Ar? ���0'01ra., .,4-i
[rCEDVErn)
MAY 16 2019 ilij
Swimming Pool Packet Revised February 2019
TOWN OF OUEENSBURY
BUILDING&CODES
SWIMMING POOL INFORMATION:
CIRCLE ONE: EDABOVE- IN-GROUND
� r
SIZE OF POOL:
MANUFACTURER: CIA e5i+ P C—
MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY):
Steel/Vinyl )1 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: -nI u� is,
SIGNATURE: DATE: ,l/f !i
Swimming Pool Packet Revised February 2019