application SWIMMING POOL PERMIT APPLICATION Off
ce use only
Permit#: RGY)+r a,-.y
Town of Quecnsbur / _pC-4Gr
Permit Fee:$!e� ,Invoice#: .3 7
742 Bay Road,Queensbury,NY 12804
IvOieS:
P:518-761-8256 www.gueensbury.net
Project Location: mar-1-� e t�t
Tax Map ID #: Subdivision Name:
=MAY118
CONTACT INFORMATION:
Ln
QUEE�# �� �,r-!!ELOPMIrf:!T
•
Applicant
Name(s): I ' a Hx
Mailing Address, C/S/Z: lz . T' -
Cell Phone: ( �>L�- 31clz 199 Land Line: ) 412- CV-(fa
Email:
•
Primary Owners
Name(s): ,u.Vru
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line: _(�)
Email:
• Installer Builder.
Business Name: CtAccvd W1
Contact Name(s): "T6-!M 8114 x, -
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line: _( )
Email:
Contact Person for Building & Code Compliance: _L.CcrtVL� , rvL
Cell Phone: _(l_) 3U) 6so Land Line:
Email: danf. i�_? IL V IJ
Town of Queensbury Building&Code Enforcement Revised March 2018
SWIMMING POOL II\91~ORIt ATION4
CIRCLE ONE: ABOVE- GROUND IN-GROUND
SIZE OF POOL: lCv
MANUFACTURER:
MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY):
Steel/Vinyl Fiberglass Gunite Poured Concrete Other I� fnelTd
4E115 r
Declaration: I acknowledge no construction activities shall be commenced prier 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:
--1PRINT NAME: LL'e_41
SIGNATURE: DATE: �U
Town of Queensbury Building&Code Enforcement Revised March 2018