applicationSWIMMING POOL PERMIT APPLICATION_[office
Use
Only
remit POOL =9 224-2029
meee ”Permit Fee:$12.5_;invoice #:ZO+24
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net Notes
Project Location:Quee ASpuC y W (204
taxmapio#:QO.V2 -\-3b Subdivision Name:
CONTACT INFORMATION:
wamet Rebect_+Kassandra Heosing
Mailing Address,C/S/2:24 Feeueees Way ueensblry NY aR OF
Cell Phone:(9 1)144 -Q5\A.bande:(518 )21-3607enaecead.@ railyoadeqna et
Prinamels:pa Ka anda Hemsing
Mailing Address,C/S/Z:
Cell Phone:(SIE)NH4-QS'A sent:|AX_J'30 1-ALO)
Email:chemnsing @taroaders ney Sel Mowe
1 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/2:
Cell Phone:_()Land Line:_()
Email:
**List all additional contractors on the back of this form
eee =aul OadeeS=ts ET wv ETceMAY26202Tw
TOWN OF QUEENSBURY
BUILDING &CODES
‘Swimming Poot Packet Revised February 2019
Ow
SWIMMING POOL INFORMATIO!
CIRCLE ONE:Cneove-Ground >IN-GROUND
size or poo:J]Ft (SUin tall)
“>4
MANUFACTURE c Y The foo)Fac lory
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.
|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:Yv
Town of Queensbury Buliding &Code Enforcement Revised December 2018