application I= ` SWIMMING POOL PERMIT APPLICATION Office Use.only
\ ...� �/ Permit#: P 1O.L--^Cc* "�20
Town of Qycensbury.
Permit Fee:$ 125 •Invoice#:21-eil'
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net Notes:
Project Location: 5 220 I 461 A.e,rag_d
Tax Map ID#: ' , 6 -'2. - / 5- Subdivision Name:
1
5ECEEIVER
CONTACT INFORMATION:
• .Applicant: JUL 2 0 2020 l io
Name(s): !1/e Jo, • • -' _ Av FJO TOWN OF UE
� �l � Q ENSBURY
Mailing Address,.C/S/Z: . ` C 0 _ f re..2. U DG C
Cell Phone: 4, 7 ) `3rs�/ `-?�/ Land Line: j_)
Email: , _ 49-e .\g _
• Primary Owner(s):
Name(s): el,*r, e ie.�..r
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line: ( )
Email:.
❑ Check if all work will be performed by homeowner only .
• Installer/Builder: Workers' Com ocumentation must be submitted with this application
Contact Name(s): , Gl' ,e
Contractor Trade: et- / afickieOdi'
Mailing Address, C/S/Z: , Qtr� -,vz,,,. , j/ d iew get","
Cell Phone: _(5 . ) 3 cc--; 0 Land Line: _( -) ?,- - , 6.a
Email: a e
**List all additional contractors on the back f this form
Contact Person for Building & Code Compliance: A 4//'i. 2 _je'
Cell Phone: ( ) Land Line: )
Email:
Swimming Pool Packet Revised May 2020
SWIMMING POOL INFORMATION:
CIRCLE ONE: ABOVE-GROUND IN-GROUND
SIZE OF POOL: 2 Y �O / /. � 54�
/''y
MANUFACTURER:
MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY):
Steel/Vinyl Fiberglass Gunite Poured Concrete_ Other
�� jyre'
Declaration: I acknowledge no construction activities shall be commenced prior to issuance of a alid 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:
f2.-1
PRINT NAME:
SIGNATURE: DATE:
Swimming Pool Packet Revised May 2020
E . 1E ll VE
JUL 2 0 2020
rowry oF
B0
un-DING P E�'euRY
- &coins
UCO
•ci)C O
�F- v c o-
crZ v co rn r � •,,F �e..\Ce
m� o� � 6q
zCC C6,'iL3n id'
r J ,
za Emaa�
EL G, CAk yak
C House v�� pobtA ,
N U V ►
U.
m3.CO cw�z CA
/63 1/
rem
4: t •
\o'
308.6-2-18 P00L-0408-2020
tf Lciii
Howard, David
500 Luzerne Rd
In ground pool
W
. D 0 Hou,,,suots
a co 00' :.:_-_lr>t
- 1 boo \ UXV
f CO b f
CC) .
4
RECEIVED
AUG 0 4 2020
TOWN OF QUEENSBURY
ZONING OFFICE
•
.6�, Fele
1d
18- 1 <estb-i
66
+1 GCS ,
Vera.-
Al-
Seest, r
8
A
is