POOL-0629-2018 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5904 (518)761-8201
Community Development - Building& Codes (518) 761-8256
BUILDING PERMIT
Permit Number: POOL-0629-2018
Tax Map No: 290.-1-53
Permission is hereby granted to: Northern Pool Scapes
For property located at: 4 BROOKFIELD RUN
In the Town of Queensbury,to construct or place at the above location in accordance with application together
with plot plans and other information hereto filed and approved and in compliance with the NYS Uniform
Building Codes and the Queensbury Zoning Ordinance
Type of Construction
Owner Name: Robert Kellogg Swimming Pool $0.00
Owner Address: 4 Brookfield RUN Total Value $0.00
Queensbury,NY 12804
Contractor or Builder's Name/Address Electrical Inspection Agency
Northern Pool Scapes
PO Box 791
Glens Falls,NY 12801
Plans&Specifications
In ground pool
$ 125.00 PERMIT FEE PAID -THIS PERMIT EXPIRES: Friday,October 4,2019
(If a longer period is required,an application for an extension must be made to the code Enforcement Officer
of the Town of Queensbury befor: ►i e e irat'. d./.
Dated at the To of Qu i 1 FA.
�I`October 4,2018
SIGNED BY: for the Town of Queensbury.
Director of Building&Code Enforcement
' SWIMMING POO PPLICATION Office Use only
E C E fl Permit#: oL
Town dQueensbury 0 �OCT �,� Cq 092'
Permit Fee:$ 1 Invoice#:
742 Bay Road,Queensbury,NY 12804 L1
P:518-761-8256 www.queensbury.net Notes:
TOWN OF QUEENSBURY
BUILDING&CODES
Project Location: a 4su' i t'lt 513,a5
Tax Map ID#: 6 3 -I 00 --a 044--40 a Subdivision Name: e r4 4i eL d A O/
Ocif), -1 -53 �s -040 -
CONTACT INFORMATION:
• Applicant:
Name(s): Ra :'&. + 1 la
sp
Mailing Address, C/S/Z: f fieilLic:4i.1 R-11 /14.31
Cell Phone: i 61$ ) .ND1 'a O1 Land Line: ( )
Email: bAu5nct%Se r*vet% AA icy',LaM
• Primary Owner(s):
Name(s): Z -erl I L L
Mailing Address,C/SAZ: /I 6 rc U ;e1 I R Y) QeE1}5l9 NY /1104
Cell Phone:_( 45] ) 5to j -1 41 Land Line: _( )
Email: bit(uEstlq $1@ r<Actro liner b .✓
• Installer/Builder:
Business Name: \k\-trx . ? \ c,cs
Contact Name(s):
Mailing Address, C/S/Z: Vzx 1 1 Okty%5
Cell Phone: ma ) Land Line: _( 5 1'6 ) Z c►3`c1i01
Email: \ BSc., s
Contact Person for Building&Code Compliance: R4beer kelitto
Cell Phone: ( ) Sid_'/OT Land Line:_( )
Email:
Town of Queensbury Building&Code Enforcement Revised September 2018
SWIMMING POOL INFORMATION!
CIRCLE ONE: ABOVE-GROUND 6N-GROUN�
SIZE OF POOL: J`b X(-l
MANUFACTURER:
MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY):
Steel/Vinyl )< Fiberglass Gunite Poured Concrete 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: e(-4- l<eLkj
SIGNATURE: U DATE: AffZvi C
Town of Queensbury Building&Code Enforcement Revised September 2018