application c Ilito
SWIMMING POOL PERMIT APPLICATION Office Use Only
Permit#: ? OL— t}Z i- Zo1
Town of Queensbury
Permit Fee:$ I ZS ; Invoice#: i-"h,`i
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensburv.net Notes.
Project Location: /✓IS/"BFa k'GI O/},
Tax Map ID #: 308 - 1- k - 25 Subdivision Name:
CONTACT INFORMATION:
• Apylicant:
Name(s): ()nN;F c I?0v i
Mailing Address, C/S/Z: if Ioes—rrsezo.i _ r u.A .
Cell Phone: ( c, i ) fI//-.0 35 . J Land Line: ( )
Email: (1• b c' n-t'� (.0 .(u nv
• Primary Owner(s):
Name(s): A pp ii C px.7
Mailing Address, C/S/Z:
Cell Phone: _( ) 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):
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:
Cell Phone: ( ) Land Line:—( }�_
Email: D E. O r PI W E
j i JUL 0 8 2019 I
TOWN Oi=QUEENSBURY
BUILDING&CODES
Swimming Pool Packet Revised February 2019
SWIMMING POOL INFORMATION:
CIRCLE ONE: ABOVE- GROUND G-GROUND
SIZE OF POOL: 3L1 lq
MANUFACTURER: V e,LIA/ fed_
MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY):
Steel/Vinyl Fiberglass V 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: v c
Swimming Pool Packet Revised February 2019