application SWIMMING POOL PERMIT APPLICATION office use only
u i Permit#: COL— 333 i
1 n of(1pienshury �� �%
�. �� ��Jh Permit Fee:$��� ,Invoice#:
742 Bay Road,Queensbury, NY 12804 J�'`�( cl
P:518-761-8256 www.queensbury.net S��{lid `I ccakt Notes:
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Project Location: 2 8 Sara-J eh Or I e, , 4- (o
Tax Map ID #: 2 9 S. !o •- I - -4 g Subdivision Name: Le 1 a.h cI Es-1-cCA-e.S
CONTACT INFORMATION:
• Applicant:
Name(s): LI ncla 13Q,11
Mailing Address, C/S/Z: 2 Sava 3 eh brt ve_, Qlt.eenohitry , Neiu Yor i'o
Cell Phone: ( ) Land Line: ( S/ g ) 79 2.23 4' 9
Email: Rba.11 39S4 g aQrn
• Primary Owner(s):
Name(s): I, i nda ia)I
Mailing Address, C/S/Z: 2 ? 5a.ra-3eh breve. , Q(Le_ ,h5bu.r_ ge_uJ York 04'
Cell Phone: _( ) Land Line: _( 5/8 ) 7 q 2,23 t
Email: R ball 3 roaielr Cow
❑ Check if all work will be performed by homeowner only
• Installer/Builder: Workers' Comp documentation must be submitted with this application
Contact Name(s): % OA, C on1O►n /1Si �`/cr,l
Contractor Trade: Qy p re.is PC015 lac S yeow.
Mailing Address, C/S/Z: 115 Wcecl 800A , /- 4-hani, Aleut) York 12 / I c) o S7,...e/
Cell Phone: _( ) Land Line: _( S/P ) 7 83 - 5 Z 3 ;1,
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Email:
**List all additional contractors on the back of this forme
Contact Person for Buildin Qde Compliance:
Cell Phone: ( ) nd Line: ( )
Email:
Swimming Pool Packet Revised February 2019
i 1
SWIMMING POOL INFORMATION:
CIRCLE ONE: ABOVE- GROUND CN-GROUN)
SIZE OF POOL: 1 'r.30 '
MANUFACTURER: 1,rn (1 cr.(cJ 19 O cl(9
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: L u' d oL i3 La
SIGNATURE: &CU. DATE: l'2 2 i q
Swimming Pool Packet Revised February 2019