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, 1 SWIMMING POOL PERMIT APPLICATION Office Use
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r Permit#: flrnt.-(b6'4-2--2an
Town ofQirscizsbixry Permit Fee $ 115 Invoice#: .3)0
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensburv.net Notes:
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Project Location: LA � V p hl \A)a
1 Tax Map ID#: 5 3LtO� -3c�I•b- I Subdivision Name: Kin S Côu r+
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CONTACT INFORMATION:
• Applicant:
Name(s): Do-n, l 1 t ana. }Y . a.n Feria cane,
Mailing Address,C/S/Z: L NJD t . , QVee61S i ) 1 )ago-1
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Cell Phone: (51g ) ,�Q 1 — (a810O Land Li • ( ) U
Email: terra CQt,r 1 t�h ia 3 j^not-.i 1 • corn .
• Primary Owners ::
Name(s): 0 ail l e -e Q-• na R VcLn Ferret C oL
I Mailing Address, C/S/Z: S -Lrn�_ CAS boQ-�
Cell Phone:_( ) Land Line: _( )
Email:
0 Check if all work will be performed by homeowner only
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• Installer/Builder:Workers'Comp documentationcu must be submitted with this application
Contact Name(s): c.John 01 o c h '1 v e- Poo' goy "
1 Contractor Trade: oO 1
Mailing Address,C/S/Z:r �j G��v ch S ��� �-}cT q Q tm a-1'1 i o"1
Cell Phone:,_( 51') �j(05 - 514 r a. Land Line: ( ) U
1 Email: C�'n O�- O- `C�G� c \Ve- - I`���•
**Listll additioMi contractors on the back of this form
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Contact Person for Building & Code Compliance: pi,,�,lt
I Cell Phone:_( ) Land rjnP_ )
Email:
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OCT 2 G00 •' en ji .
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4 TOWN OF QUEENSBURY
BUILDING&CODES _
Swimming Pool Packet Revised May 2020
Swimming Pool Packet Revised May2020
SWIMMING POOL INFORMATION:
CIRCLE ONE: ABOVE-GROUND IN-GROUND
SIZE OF POOL: / (J X 3 Y0
MANUFACTURER: TrrlpfJlt ,i p 00/6
MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY):
Steel/Vinyl .J/ Fiberglass Gunite Poured Concrete C p Other
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: I O.-Nl2 kR.-T: fl-0-n . ck-A CkkAar\ rc ccui
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SIGNATURE COX ('r. -e.w, DATE: ID -P1`a(-
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