POOL-0103-2021 SWIMMING POOL PERMIT APPLICATION office Use only
Permit#: P00 L- 0\0b '1021
Permit Fee:$ :Invoice#:
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.gueensbury.net Notes:
Project Location: ell Civ s-to kct
2 �. �- 2Z. tEtVfTax Map ID#. 0 . 7 Subdivision Name2021RY
CONTACT INFORMATION: ENSB S.CODES
• Applicant: /
Name(s): �a. Jli W14��5
Mailing Address, C/S/Z: e l"Y1 07 N61!%= ivuLfl_
Cell Phone: (5i ) ';:TO1 5 n I Land Liner
Email: LWcei-sm-el (It awdit • Cpm
• Primary Owners : _
Name(s): �Gv
Mailing Address, C/S/Z: S"�1M-e e 5 -e
Cell Phone:_( ) Land Line: _( )
Email:,
❑ Check if all work will be performed by homeowner only
• Installer Builder: Workers' Comp documentation must be submitted with this application
Contact Name(s): cA
Contractor Trade:
Mailing Address, C/S/Z: 15 Qo apnCfo o(-)S�) '
Cell Phone:_(J�L� ) —RI- !2q9f//?Lan Line: _( )
Email:
"List all additional contractors on the back of this form
Contact Person for Building & Code Compliance:
Cell Phone: _( ) Land. Line: _( )
Email:
Swimming Pool Packet Revised May 2020
I
• Installer/Builder: Workers' Comp documentation must be submitted with this application
Contact Name(s): �` P �evl
Contractor Trade: ��
Mailing Address, C/S/Z:
Cell Phone: (.51- ) O- - VO<9 Land Line:—(_)
Email: r
• Installer/Builder: Workers' Comp documentation must be submitted with this application
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line: _( )
Email:
• Installer/Builder: Workers' Comp documentation must be submitted with this application
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line: _( )
Email:
• Installer/Builder: Workers'Comp documentation must be submitted with this'application
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line: _( )
Email:
• Installer/Builder: Workers' Comp documentation must be submitted with this application
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line: _( )
Email:
Swimming Pool Packet Revised May 2020
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SWIMMING POOL INFORMATION:
CIRCLE O.NE: ABOVE-GROUND Cf-GROIJ 3D
SIZE OF POOL:
MANUFACTURER: != ��t� �5
MATERIALS USED IN CONSTRUCTION:(CHECK ALL THAT APPLY):
. .Steel/Vinyl Fiberglass Gunite Poured_Concrete_-- _-_- Other k
Declaration: I acknowledge no constructibn 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
lziws and ordinances and in conformance with focal zoning regulations. I acknowledge that I have-read the
application and plot plan requirements and i,or my agents, will obtain a certificate cif'compliance bef6re use
of the pool.
I have read.and agree to the above:
PRINTNAME: �►�N�'ES C(���L -� �C1�. T
SIGNATURE-. � � DATE:
Swimming Pool Packer Revised-May 7020 .
D E C E O W F 290.-1-22.9 POOL-0103-2021
Castler, James & Leyla
139 Chestnut Ridge Rd fl
°��� '�� „� In ground pool g
TOWN OF OUEENSBURY
BUILDING& CODES
c7 I� •ar •-o• REVISIONS uA gK
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—' DETAIL �e1 REC=r � s
FILE. �®
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e-i i-oo--o d 001 are, miller h YM PIIW�M'11 f11T')
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re squire ants specific o y ( w o �
'e CK , r ulrod lo meet all appt b
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14 r 9 pools, spa 81.
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of inspection.
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PROPOSED
POOL & PAW
x o o PLAN
TO EENSEURY TOWN OF QUE NSBURY . naic SCALE
L BUILDING DEPARTMENT
BUILDING & GO®ES EPTa Based on our limited examination,compliance
Reviewed S with our comments shall not be construed as
indicating the plans and specifications are in
Z full compliance with the Building Codes of
®21tQ: New York State.
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