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' ., „ SWIMMING P _ARC Office Use Only
TECIEDVE
Permit#: OWL - OHS- ---ZO( i
Town of(Zuccn sin.ry
742 Bay Road,Queensbury, NY 12804
MAR 2 5 2019 Permit Fee:$ I Z.�.1 ); Invoice#: 1 3Z�v
P:518-761-8256 www.queensbury.net Notes:
TOWN OF QUEENSBURY
BUILDING&CODES
Project Location: 37 ( ti+1ii 4 r e .
Tax Map ID #: 301 . J 1 -3 r 35 Subdivision Name: P))(lit WP,S
CONTACT INFORMATION:
• A licant: ,�,
-UcA
Name(s): L�,4Vl L.l and ti + PF
Mailing Address, C/S/Z: 31C.Ca � r/1'1 ny i'vQ. CpriStlq13 `',
Cell Ph ire: ) 7 Li ( Land Line: (`J ) iq_ J3(L
Email: 1���t& �3 Oa or
• Primary Owner s :
Name(s): I 1 OLIT tt(C
Mailing Address, C/S/Z: 1 CD ) I ilf ii l n' (�\
rye �'`
Cell Ph ne: 5l -u _.(AL\ ( LandX Lne: J 3l 1 0L)g q
Email yt t C' 0f tY Gyn
❑ Check if all work will be performed by homeowner only
• Installer Builder: Workers' Comp documentation must be submitted with this application
Contact Name(s): V 0.a ;vJ 4Ackt`
Contractor Trade: •,,.4c,N\t,t
Mailing Address, C/S/Z: 14\ . G44,s w\\S \''\ 0-9z1
Cell Phone: _( S i% ) -11 KL,Sl-1 Land Line: _( 51 ) 1 t1 L-cjrw3
Email: -SCE S � op c-'\ . (.-
**List all additional contractors on the back of this form
Contact Person or Buil i g & co ecompliance: 1 t \fin D r IA)
Liu-
Cell P one: _( )% )010 ) U`3) and Line: (5I ) 1C�Aj o - LP
Email:OV Gti C5 Onifit t,1' �.d --)
Swimming Pool Packet Revised February 2019
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•
• Installer/Builder: Workers'
Comp documentation must be submitted with this application
Contact Name(s): Iol tTLfth l C,
Contractor Trade: Et ctri it
Mailing Address, C/S/Z: f b 'US LC,1Q, f 1k ;ritiak rC )
Cell Phone: 5I 1 I " dil 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:
• 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 February 2019
w •
SWIMMING POOL INFORMATION:
CIRCLE ONE: ABOVE- GROUND Cif;
SIZE OF POOL: 1Lo X 3 42
MANUFACTURER: 1--- \c.N-<\ - .--(A. .
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: LJrth&\\( 3CSCt +
SIGNATURE: Lt 9? 4 'C41L1DATE: 3023 I°l
Swimming Pool Packet Revised February 2019