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applicationSWIMMING POOL PERMIT APPLICATION|office use oniy permit TOO1=0232,-2020 Permit Fee:$25 _;voice #:2248 Notes:742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.queensbury.net Project Location:3 Suwset Dewee Tax Map ID #:e2zAn295 Q-2-5°Subdivision Name: CONTACT INFORMATION: *Applicant: Name(s):LloeeaerD MAGrA LENO Mailing Address,C/S/2:_3 SUNSET Dawes Aucenspupy NY 1Z¥OF Cell Phone:_((Aw )296-215 landline:(J}w/a Email:__\WesT Rucker 1@ sN.com ¢Primary Owner(s): Name(s):one Mailing Address,C/S/Z: Cell Phone:_(), Email: ©Installer/Builder: Business Name:See Contact Name(s): Mailing Address,C/S/Z: Cell Phone:_() Email: Contact Person for Building &Code Compliance:a yeCellPhone:_(),Land Lin Email: ‘Town of Queensbury Bulding &Code Enforcement Revised December 2018 ceSWIMMINGPOOL INFORMATION: CIRCLE ONE:CABOVE-GROUND >IN-GROUND SIZE OF POOL:Z MANUFACTURE! MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY): Steel/Vinyl_~Fiberglass Gunite Poured Concrete Other _ Declaration:|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.|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 NAME: SIGNATURE:DATE: “Town of Queensbury Bulding &Code Enforcement Revised December 2018