application dot SWIMMING POOL PERMIT APPLICATION Office Use Only
Permit#: FdOV 41 1
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Permit Fee:$ 1 -(1-4-1 Invoice#: (0l3
742 Bay Road,Queensbury, NY 12804
P: 518-761-8256 www.queensbury.net Notes:
Project Location: ,) 6 C.)- eai 1 '�\re_ n5 .i
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Tax Map ID #: 299. � Subdivision Name: 4. -ow5
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CONTACT INFORMATION:
JUN172019
TOWN OF QUEENSBURY
• Applicant: COMMUNfTY DEVELOPMENT
Name(s): \4;- c\
Mailing Address, C/S/Z: 2c, ee (Qua Q../Sktkp r Zgo`i
Cell Phone: ( ) 40 9 o qA Xe Land Line: ( ) /\/10
Email: Joy 7xd 61- @ gr,(4)1L. CO"-/
• Primary Owner(s):
Name(s): Ato Q
Mailing Address, C/S/Z:
Cell Phone: ( 1 (1/141 _ Land Line: ( _)
Email:
❑ Check if all work will be performed by homeowner only
• Installer/Builder: Workers' Comp documentation must be submitted with this application
Contact Name(s): onc>
Contractor Trade: s 1\s- gro., oDk-i
Mailing Address, C/S/Z: L1 c MA:r( Cal, > (1 N / 11- r04
Cell Phone: ( ) Land Line: ( ,5� 8 ) 7 1 3- R 2 1
Email: (i>od s 6:t..5 j (IN cav1
**List all additional contractors on the back of this form
Contact Person for Building & Code Compliance: !' "\
Cell Phone: _( `mil ) (0`to 92.gK Land Line: _( ) rIJ�
Email: r)Oe_ 7AO 6S 3I%V
Swimming Pool Packet Revised February 2019
SWIMMING POOL INFORMATION:
CIRCLE ONE: ABOVE- GROUND IN GROUND
SIZE OF POOL: l hX 3
MANUFACTURER: C? Oc L5 )
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:
SIGNATURE: `'�^ DATE: (.// 7 f/%
Swimming Pool Packet Revised February 2019
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