applicationSWIMMING POOL PERMIT APPLICATION Office Use Only
permit #,
PoGW.*
C30+22.0
owen of Queensbury Permit Fee:$125)_;Invoice #:Ly,742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net Notes
Project Location:POCY UICC
Tax Map ID #:325400 2.90 1-1 |e Subdivision Name:_V/#%
CONTACT INFORMATION:
*Applicant:
Name(s):seo Posiore.
Mailing Address,c/s/2)__1S Martel)Baad @aeenscurd KN
Cell Phone:(FiI%)KIT -Aloe.Land Line:_{}
emai:SEOSINE UG Yana CON
«Primary Owner(s}:
Name(s)_]AS70N SUSI.
Mailing Address,C/S/2:15 MOitPl)Boh GauperSbim4 KN 12804
Cell Phone:(SYR)“Sit OUWAC:Land Line:_(a
Emails JOOSTOre DIVE Ya nce.COW)
fd.cheek 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:_()tand Line:_()
Email:
**tist all additional contractors on the back of this form IN
Contact Person for Building &Code Compliance:
Cell Phone:_(}Land Li
Email:
‘wiemiig Pool Packet Revised May 2020
SWIMMING POOL INFORMATION:
CIRCLE ONE:ABOVE-GROUND rworouro
size of oot:_Z24
MANUFACTURER:FUL t Pools
MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY):
Steel/Vinyl vA Fiberglass Gunite Poured Concrete_v 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
taws 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:__ésepn HiStfyeSIGNATURE:—_oe oare:_LS 12000)
‘swimming Pool Parker Revised May 2020