application it SWIMMING POOL PERMIT APPLICATION Office Use Only
Permit#: PDt L - b-c)(5- ZU 2_3
Town of Queensbury Permit Fee:$ i 2-5 ; Invoice#:��p
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net Notes:
Project Location: 3 Spruce Ct,Queensbury,NY 12804
Tax Map ID #: 302.14-1-66 Subdivision Name:Click or tap here to enter text.
CONTACT INFORMATION:
• Applicant:
Name(s): Matt O'Connor
Mailing Address, C/S/Z: 3 Spruce Ct, Queensbury/New York/12804 O W EE -p
Cell Phone: (518 321 8411 ) Land Line: ( NA ) `-'"'�I
Email: mocon01@gmail.com I JUL ) 5 202) . I �{ V
• Primary Owner(s): TOt 11 -t
Name(s): Matt O'Connor ! ----.
Mailing Address, C/S/Z: 3 Spruce Ct, Queensbury/New York/12804
Cell Phone: (518-321-8411) Land Line: ( )
Email: mocon01@gmail.com
❑ Check if all work will be performed by homeowner only
• Installer/Builder: Workers' Comp documentation must be submitted with this application
Contact Name(s): Sandra Barlow
Contractor Trade: Pools Plus—Pool Installation
Mailing Address, C/S/Z: 45 Main St, Queensbury/New York/12804
Cell Phone: (NA) Land Line: (518-793-2929)
Email: mypoolsplus@yahoo.com
**List all additional contractors on the back of this form
Contact Person for Building & Code Compliance: Dave Barlow /5‘..4.4,,„ ( iet,,J
Cell Phone: ( ) Land Line: (518-793-2929)
Email: mypoolsplus@yahoo.com
Swimming Pool Packet Revised May 2020
SWIMMING POOL INFORMATION:
CHECK ONE: ❑ABOVE- GROUND MIN-GROUND
SIZE OF POOL: 16 x 36
MANUFACTURER: Clictroiltplerrierfir textP6D/3
MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY):
Steel/Vinyl ® Fiberglass ❑ Gunite ❑
Poured Concrete ❑ Other ❑ (Explain: )
Declaration: I 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. 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 and agree to the above:
PRINT NAME: Matt O'Connor
SIGNATURE: h enter text. DATE: Click or tap here to enter text.
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1//10,a"I.. 0
Swimming Pool Packet Revised May 2020