applicationSWIMMING POOL PERMIT APPLICATION Office Use Only
:permit:
FOQL-
O1\92.-'202.)
Paes Permit Fee:$§_\2"invoice #:252.2.“742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net Oe:
Project Location:25 (£4 Dow bow &
Tax Map ID #:277./7—/-/F Subdivision Name:__4“/4—
CONTACT INFORMATION:
¢Applicant:
Name(s):oe ER Wayss
Mailing Address,C/S/Z:_25 A€aDow La vé.,Queswshuny,NY /apoy
Cell Phone:_(778 )_339-Ay¢¥landline:($76)2@/-26.72.Email:__PHa¥isc?JE B Mose .Corn—
*Primary Owner(s):
Name(s}:SQ ype
Mailing Address,C/S/2:
Cell Phone:_()land Line:_()
Email:
CO Check if all work will be performed by homeowner only
*Installer/Builder:Workers’Comp documentation must be submitted with this application
Contact Name(s):di chard SF.Geman
Contractor Trade:“Upstate Ew ter or)
Mailing Address,C/S/Z)_700%Aeccust Greve R24,Grroverin GhWYR$23
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:
his [—7
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APR 22 2020
‘Swimming Pool Packet L Revised February 2019
*»Installer/Builder:Workers’Comp documentation must be submitted with this application
Contact Name(s):CaMEROW PRown>Contractor Trade:BRown ELECTRIZ
Mailing Address,C/S/Z:_2 Qveéy Diawa 4AM,Rveews horny,V¥i2F0Y
Cell Phone:_(5/&)204 -2°97 Land Line:_()AonEmail:__Cambrewwo yahoo.can
*Installer/Builder:Workers’Comp documentation must be submitted with this application
Contact Name(s):Gswe Bartow
Contractor Trade:(Gas)GsD Com£REFEIG s ELECT:Sves -
Mailing Address,C/S/Z:_226 Bartow Rod,Buskink ~r~Y /Aoae
Cell Phone:_(F1€)2a//-09 59 land line:(3/8)953-9810
Email,A/a
+Installer/Builder:Workers’Comp documentation must be submitted with this application
Contact Name(s):
Contractor Trade:
Mailing Address,C/S/2:
Cell Phone:_()land Line:_()
Email:
+Installer/Builder:Workers’Comp documentation must be submitted with this application
Contact Name(s):
Contractor Trade:
Mailing Address,C/S/2:
Cell Phone:_()land Line:_()
Email:
* Installer/Builder:Workers’Comp documentation must be submitted with this application
Contact Name(s):
Contractor Trade:
Mailing Address,C/S/Z:
Cell Phone:_{1 Land Line:_()
Email:
‘Swimming Poot Packet Revised February 2020
=SWIMMING POOL INFORMATION:
CIRCLE ONE:ABO ROUND IN-GROUND.
SIZEOF POOL:220 F+.
manuracturer:
€V6LUT7o»PoolS
MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY):
Steel/Vinyl_“_—Fiberglass___—=—s—s«Gunite ___—=s PouredConcrete___==—s“Other__
Declaration:|acknowledge no construction activities shall be commenced prior to issuance of a valid permit.
|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.|acknowledge that |have read the
application and plot plan requirements and |,or my agents,will obtain a certificate of compliance before use
of the pool.
Ihave read and agree to the above:
PRINT wae:LetinHopsSIGNATURE:pe as pate:_Y,[3foore
‘Swimmiog Pool Packet Revised February 2019