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SWIMMING POOL PERMIT APPLICATION Office Use Only
. '° <, Permit#: Q�_0 t 2--213\ci
Town of Queensb€try
Permit Fee:$ 12-- ; Invoice#: I
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net Notes:
Project Location: PC &X�
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Tax Map ID #: .., � m, a"i s. 0 Subdivision Name: J_( arl
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CONTACT INFORMATION:
• Applicant:
Name(s): AP IA-pi Ati-1 i N a
Mailing Address, C/S/Z: 17� F 4i2L I *6
Cell Phone: ( t i ) 7 d 24kit Land Line: ( )
Email: 51-ce1a.'n 12.63a yew.C.,i,..
• Primary Owne�rs):
Name(s): g ,e_et1 (F�d ti4,144M)%
Mailing Address, C/S/Z: i'73 F 0- ith,1 et-
Cell Phone: _( S 1 4j' ) 3i7 5/3 D Land Line: _( )
Email: (N bed, 3 e. goltit.
El Check if all work will be performed by homeowner only
• Installer/Bu' er: Workers' Comp documentation must submitted with this application
Contact Name(s): ' J (N.Q. .4VC
Contractor Trade: „,1 krO O \ i cOSJ8,_ i.it-‘
Mailing Address, C/S/Z: C Th ' A" ` 1 olt
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Cell Phone:_( tc< ) i� Lan Line: _( 51 ) "14 - 4W1(
Email:_,, '° ,; fa g " `` '?
**List all acIL itional contractors on the back of this form
Contact Person for Building & Code Compliance: -,:37,4)-Aur _RogiS
Cell Phone: ( ) Land Line: ( U )
Email:
Swimming Pool Packet Revised February 2019
SWIMMING POOL INFORMATION:
•
CIRCLE ONE: ABOVE- GROUND IN-GROUND
SIZE OF POOL: r) t),_)..A-i01/49--"
MANUFACTURER: C
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:
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PRINT NAME: 6a � i
1.t•1,5
SIGNATURE: DATE:
Swimming Pool Packet Revised February 2019