application SWIMMING POOL PERMIT APPLICATION offi•
ce Use Only
Permit#: Rot-- 4 3I- a-e /l
r..17 of Q{mrnsbun ' -it/ ^�
Permit Fee:$l ;Invoice#:/7/�--•
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensburynet Notes:
Project Location: 16 f!on fWloi'J pd,
Tax Map ID #: 308 , 1 e - I '.4 Subdivision Name: C o r d C (os e
i
ECLoV1E
CONTACT INFORMATION:
JUN212019
• Applicant: IP
TOWN OF t►
Name(s): °, - it 1, r • �,p ) C•►r _ Q FENSB
Mailing Address, C/S/Z: /to e e ll!ia . Y OPMENT
Cell Phone: ( 5I ) 74/1/ — Wi e Land Line: ( )
Email: 6ro, /99ye ahb00ACO✓I'1
• Primary Owner(s):
Name(s): sk,vl E
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _( )
Email:
El Check if all work will be performed by homeowner only
• Installer/Builder• orkers' campLdoc ntation must be submitted with this application
Contact Name(s): /� roll c/roll iCA" cep,c 91'S p JN n e ‘ - L? v-,-r —_
Contractor Trade: l7 ( # F 4. '
� 2S j
,Mailing Address, C/S/Z: $' ,,0 IV t ,Je 1,1s b(I _
�,(tcell Phone: _( ) - ? Land Line: ( Pa V ) -??e - Ss`s'a
Email: in • vb,,, e.o 6. • Co ep‘
**List all additional contractors on the back of this form
Contact Person for Building & Coc . Compliance:
NI 1 J 4 f p yc� 5 6 - 41 --
Cell Phone: _(,47. ) `}t// ' I Land Line: _( ) e
Email:
Swimming Pool Packet Revised February 2019
SWIMMING POOL INFORMATION: •
CIRCLE ONE: ABOVE- GROUND GROUND
SIZE OF POOL-
MAN UFACTURER: /54-4)/Pak;
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: ) 1--) ! " Bi
SIGNATURE: 6 . ' DATE:
Gb-1
•
9 Swimming Pool Packet Revised February 2019