application SWIMMING POOL PERMIT APPLICATION office
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euse Only
Permit#: 1:1119 t-- Mb.2oZ�
II Permit Fee:$ 123 ;Invoice# 2`:
742 Bay Rdad,Queensbury,NY 12804
P:518=7618256 wvuvii.pueenshurv:net Notes: - ::__ --
Project Location: 10 L> A.Li I .Q': `t
Tax Map ID#: yor,lo / 7 / Subdivision Name: rc7 • ,,S"liar
CONTACT INFORMATION:,
• Applicant:
Name(s): I CGv\COA Pot-AS
Mailing Address, C/S/Z: I 56.1 S De\Ci(R c v 60SCI kc /-.9= i a-r i,Al `/ /Z I I()
Cell Phone: ... 1r )Roll .- 7.3`i' - Lad Line: ( 5iir ) P- y 1 y c�,�t /I�..
Email 8 I . a.� ftvvl`Occ. cLc✓1 Cor-ak cccc'AS • C c' \
• Primary Owner(s):
Name(s): A:c-1�i- VI/ -ei e_TAk Q_Ao,r'Mailing Address, C/S/Z (o . i.,0( iU. C-A-,„ Ckv,o_slYlSlo�a ,)Q-,1. .(7 9-01 '-
Cell Phon :_( 515.. ) �C)—r339.‘ Land Line: _( )
Email: YVkb(A C C vvt.J i;Q-‘f-'. O'1St)I k-OYlei ,C-o
h allhomeowner only
❑ Check if work will be performed by
• Installer/Builder: Workers'Comp documentation must be submitted with this application
Contact.N me(s): Co-nLo\"o . (c )�S
Contractof Trade: IGv(: - ...1 ck. tV f j
Mailing Address, C/S/Z: 15-Co S Aft/oac.Jt )s (' � Ivi`t-t'l(t,Vtyv NV l Zl( 0
Cell Phon:_('5i - - :. �L.and Line: _(�)
Email 6r• v\,.^ vs ' C:cY\COircx r9-C IS ` <`rll%i/I
*List all additional contractors on the back of this form
Contact Person for Building & Code Compliance:
Cell Phone: _ Land Line:_ ---N`"
Email: r; l=fg ''11 VI If
Swimming PoolPool Packet Revised May 2020
.
• Installer/Builder: Workers'Comp documentation must be submitted with:this application
Contact N1ame(s):_ .70,z .'r (
Contract it Trade: g..-'l ct.: �Ien- v-N'-c
,Mailing A dress, C/S/Z: _
_( K ) ?�-71a—CY 3 (. Land Line: _( )-
Cell Phone: Si -7,.
Email: 30•Q C-.) -ve c-A-r; c •- C L n
•
• Installer/Builder: Workers'Comp documentation must be submitted with this application
Contact ame(s):
Contract r Trade:
Mailing Address, C/S/Z: -
Cell Phonh:_( ) Land Line: _( _ )
Email:
• Installer/Builder:Workers'Comp documentation must be submitted with this application
Contact I\ame(s):
Contractor Trade: •
Mailing Address, C/S/Z: •
Cell Phonp:_( ) Land Line: _( )
Email:
•
• Installer/Builder:Workers'Comp documentation must be submitted with this application
Contact Name(s):
Co ntractd r Trade:
Mailing.Alddress, C/S/Z:
Cell Phonle;_(. ) Land Line: _( ) _
Email: I
• Installer/Builder:Workers'Comp documentation must be submitted with this application
Contact Ilrame(s):
Contractor Trade:
Mailing Address, C/S/Z: .
Cell Phonle::_( ) Land Line: _( ).
Email:
Swimming Poo Packet Revised May 2020
SWIMMING.POOL•INFORMATION:
CIRCLE ONE: ABOVE-GROUND IN-GROUND
( .1 ,04,1)tfi , /0 V ZO
SIZE OF POOL: w , ' -
mil,a svi to(
MANU ACTURER: :
MATE lALS USED IN CO -ECK ALL THAT APPLY):
Steel/Vinyl Fiberglass_lass_ Gunite Poured Concrete Other
Declaration: I acknowledge no construction activities shall be commenced prior to issuance of a valid permit.
I certify tha the application, plans and supporting materials are a true and complete statement/description of
the work p joposed,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. I acknowledge that I have read the
application and plot plan requirements and I,or my agents, will obtain a certificate of compliance before use
of the,pool.
I have read nd agree to the above: •
'X c
PRINT NA E
wA v
SIGNATURE:. � DATE:
G / . `Zo
Swimming Pool Packet Revised May 2020