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application
` . . ._ f.�_ ..�. SWIMMING POOL PERMIT APPLICATION Office Use Only y. Permit#:Co 0,L._ D 4 - 20LO Town of Quccnsbury Permit Fee:$ 12- ;invoice if:Z Z 742 Bay Road,Queensbury,NY 12804 Notes: P:518-761-8256 www.queensbury.net Project Location: 4 M(. c,11 rO in, (v) HZ- � ` Subdivision e ( .. II i�- TaxMapID #: - J ---111 ; i AUG 03 1020 I P I CONTACT INFORMATION: TOWN Oepp�OUEE , }r_ii ,' BUILPINL7I { : D;-1 • Applicant: Name(s): kim.eE, -c- r W2/Gib— ' Mailing Address, C/S/Z: 51-5* Me6CHRdfv 14+-4'e Q s.8c /Z yl L'Y 1 Z©o 4 Cell Phone: ( 518 ) 366- ) I'7 o Land Line: (S i 8 ) 7 4Z - 633g Email: kdw•owseQ., roc-drwrinQr. dow. • Primary Owner(s): Name(s): /6d-taE2c Wi2I611-T QuEFNsBtioty UV IZBo`/ Mailing Address, C/S/2 IA Q Ec.4iio,v ig-gdo Cell Phone:_( 519 ) 3b b - 1 1.1 ° Land Line: _( 5r 8 ) 7 9 Z - b 3 3 8 Email: kdw.owseQ roadru+AIA.efr • c°w- ❑ Check if all work will be performed by homeowner only • Installer/Builder: Workers' Corn documentation must be submitted with this application Contact Name(s): NciitOrtdctei,, c15 uPS pc( i ; nC' . Contractor Trade: 12n, ' c - P..I'c'� ►`,,s/-cc 1Ict 4r(7).-L. Mailing Address, C/S/Z: R oo I-eVC'{d Nti-unsboA..ii Cell Phone: ( 4^S CC 1 Land Line: _( U�jjc) `4Dr . _� J -a_( � � )-3 `f Email: ‘(\-c > A.d.;,r,r-:.-de,,0,kP3 )S - C°%''i **List all additional contractors on the back of this form Contact Person for Building & Code Compliance: \\c Oi Cell Phone: _( ) Land Line: ) Email: - Revised May 2020 Swimming Pool Packet SWIMMING POOL INFORMATION: CIRCLE ONE: ABOVE-GROUND ( IN-GROUND l_\ SIZE OF POOL: I i //1 / . ....,may .�� MANUFACTURER: C_,Gfi ` d f I G-/� .N%'�_-, Stri MATERIALS USED IN CONSTRUCTION (CHECK ALL IAT APPLY): Steel/Vinyl ./ Fiberglass Gunite Poured Concrete ' Other /Vin y \s 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 NA : kimov-4et- -. t4/4/O tf( SIGNATURE: C\ DATE: 1 '3 l'20 20 • Revised May 2020 Swimming Pool Packet