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SWIMMING POOL PERMIT APPLICATION Office Use Only Permit#: FO L-- Town of Queensbury Z� Permit Fee:$ ; Invoice#:285k 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.queensbury.net Notes: Project Location: 7 f-jr1 p Covric Dv 4h't, ,/\( Tax Map ID #: 73-4 Subdivision Name: CONTACT INFORMATION: • Applicant: Name(s): Thom N.s. Rnn(/P Mailing Address, C/S/Z: 7 Br'jys Cot/rT„ Ouee,, s by is NY , 1 Cell Phone: ( -i8 ) R!n - 9s-92 Land Line: ( ) Email: TRoode& IVY cp , rr• Conn • Primary Owner(s): Name(s): ihor)G.s I- Amy lCo©i�L' Mailing Address, C/S/Z: 7 Ir, CovrT, �uaeAJbury IVY 1.2 8c 9 Cell Phone: _( 5-/ $ ) )Y - 9'9 9 Land Line: "_( Email: TRondf, ct iv rcelp. 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): Pon j,( P Contractor Trade: Mailing Address, C/S/Z: L/.S ('€ 14 ST.) Qt.e, 3 L'r /A/� )" 1 Y1P f Cell Phone: _( ) Land Lir _( 471 ) 7 ? — 02-904 9 Email: **List all additional contractors on the back of this form Contact Person for Building & Code Compliance: Vl car Cell Phone: ( ) Land Line: ( _ ) _ Email: ramEovi.w . ')_ JUL 28202U Ll TOWN OF QUEENSBURY BUILDING& CODES Swimming Pool Packet Revised May 2020 • SWIMMING POOL INFORMATION: CIRCLE ONE: ABOVE- GROUND IN-GROUND SIZE OF POOL: I6 X3 MANUFACTURER: MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY): Steel/Vinyl Fiberglass Gunite Poured Concrete Other Declaration: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: c>/1,7 I 4'Se-- SIGNATURE: �, DATE: Swimming Pool Packet Revised May 2020