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oe SWIMMING POOL PERMIT APPLICATION Office Use Only Permit #:POOL —O14\-2029 fete Caendbary Permit Fee:$12S __;invoice #:4942 "742 Bay Road,Queensbury,NY 12804 'y:518-761-8256 www.queensbury.net Notes: Project Location: 2x2LizeweRaTaxMapID#:206 .\6-\-2—__ Subdivision Name: CONTACT INFORMATION: .licant: Name(s):Francis MW Perce Mailing Address,C/S/Z:571.a Uerne Ra Osby NY jd Cell Phone:(S\¥_)“3a~)305 landline:(SiS )198-9369 Email:_Deru @ hotmail.Conn ©Primary Owner(s): Name(s):Fras MW “Reread Mailing Address,C/S/2z:STO Luverne Wd Gsiny NY [a L Cell Phone:(518 _)4232.7205 landline:(SiS )I S-O2W% Email:Dersutty @ Wot mai.Cans c 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):__Sfrayu e's Mermui\Pols €Spus 66¢—(michen!Borel) Contractor Trade:Enground Feel Losuther Mailing Address,C/S/Z:00 Broa vey Suite 44 fot Glwod VY \2Q3 Cell Phone:_(_S'y_)307 —6258 land Line:(_$13_)__247 -9270 Email:Spragu es Pools M Peron,Ker **List all additional contractors on the back of this form Contact Person for Building &Code Compliance: Cell Phone:_()Land Line Email: ‘Swimming Pool Packet Revised February 2019 SWIMMING POOL INFORMATIOI v CIRCLE ONE:ABOVE-GROUND IN-GROUND size or Poot:18 x 36. MANUFACTURER:_Loyeval Pevls/Tusrmre®_s?POOLS MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY): stee/Vinyl_X 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:Fay MN,Ceasumr SIGNATURE:A m pate:3 [pe]asu> ‘Swimming Pool Packet Revised February 2019