POOL-0306-2023 J
,, - •. SWIMMING POOL
n �ii
Office USr.Only
_ PERMIT APPLICATION Permit ti:�G�L- b3a�-�'•��
rel,n c C nsb:rn
742 Bay Road,Queensbury,NY 12804 Permit Fee:$ fso'';invoice t#: 6 14 S
P:5i8-761-8256 www.queensbury.net Flood Zone? Y /� Reviewed By: I \
,
Project Location: i.�tl9:6-\-yl4 CaCeiR& !
Tax Map ID #: R4O, — / - ! Subdivision Marne:
Proposed Install Date: v 2\r- \' `7 07 .-2-, I C lE l d E
D
SWIMMING POOL INFORMATION (please fill out completely):
JUN 0 6 1023
TYPE: CHOOSE ONE: TOWN OF QUEENSBURY
BUILDING&CODES
-r-ABOVE-GROUND !/ UNHEATED
V.-IN-GROUND (inc.partially) V HEATED(pool cover heater; R-12.req'd.)
COST OF CONSTRUCTION: f(7 O
SIZE OF POOL: i 10 Kc
MANUFACTURER: L(q-A-V14` !'Yl
MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY):
Steel/Vinyl Fiberglass V Gunite Poured Concrete Other
t 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: � n .� -Jrb_'d\i\\�i`QC @OSS
(1U, DATE: I Z., 7 7
SIGNATURE;
,/f
-: __._-- v_-- - Revised Jug 2022
/ CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): 00
k C S
Mailing Address,C/S/Z: - C1C":21 0Ovi
Cell PhOne: ( S‘v( ) 7?-)2-k (1)3th Land Line: (
Email: :lc(•coSc
• Primary Owner(s):,
Name(s): ( Nrt\ CCOS •
Mailing Address,C/S/Z: C--a.45
Cell Phone: (SfL„.) ( Lknd Line: j5 )
Email: TCSQ .S o
0 Check if all work will be performed by property owner only,
Installer/Contractor: (List all ad
ditiral Contractors on the back of this form)
Contact Name( ):
Contractor Trade: =.iNv-1.,),(N cL vzmo.
Mailing Address, C/S/Z: Afro(.0\ix)z.Lan Line. ft)
-,,
Cell Phone: )- Cf11 S L Crikv
Email: **?.--A-1 e-A c:Th)LANN-NrC-Aff ccc - **
**Workers' Comp documentation must be submitted with this appticatton
Contact Person for Compliance in regards to this project: LCOS.S
Cell Phone: 6-6 ) SZA €03.31 Land Lind: (51 )
Erna: -.-S'(1.S'OSS\r),Cril A A
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