application r
SWIMMING POOL PERMIT APPLICATION Office Use Only
Permit#: exL- 03/1(- .020
Town of(Zeensbury Permit Fee:$ I ; Invoice#: 7-S
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net Notes.
1.2 $ k woop Dr-ye-
Project Location:
Tax Map ID #: 290, 3' ( - 6.7 Subdivision Name:
CONTACT INFORMATION:
• Applicant:
Name(s): ToDD 3o124.A4/6
MailingAddress, C/S/Z: 12 6A.0ekweob Or . Qveas&JRy NY /•0'oS'
Cell Phone: (S14 ) 796 9 29c) Land Line: ( )
Email: .oddba /,,•J @ '. 0 . Go.r+
• Primary Owner(s):
Name(s): Tow d• sus v en&( s1^16
Mailing Address, C/S/Z: /2 Saiziciation bL .i&
Cell Phone: _( ) Land Line: _( )
Email:
Xtheck if all work will be performed by homeowner only
• Installer/Builder: Workers' Comp documentation must be submitted with this a ' tion NIA.
Contact Name(s)T .. ,-t..)cI-ar Pool. seie. r-.7r.�-io`Si, i'
Contractor Trade: roc ' G v
Mailing Address, C/S/Z: i, oo ivy- RcE,v L.' cf.( VY I253A
Cell Phone: _(,S/g ) S i y• Lan . .,_)
Email:
**List all additional contractors on the back of this form Po t,,.1,r— pe- m,,,�
Contact Person for Building & Code Compliance: ISVI., ,;,iT
Cell Phone: _( ) Land Line: ( )
Email: ---
,, ,, ,
JUN252020 ; ,
TOWN OF QUEENSBURI
BUILDING&00 ES
Swimming Pool Packet Revised May 2020
SWIMMING POOL INFORMATION:
CIRCLE ONE: ABOVE- GROUND `a^: -IN-GROUND
SIZE OF POOL: 24 &.aUntb
MANUFACTURER: R,D t A APT
MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY):
Steel/Vinyl Fiberglass Gunite Poured Concrete Other 70
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: roil) init -,Q-/1/6
SIGNATURE. DATE: (s/A 2026
Swimming Pool Packet Revised May 2020