application SWIMMING POOL PERMIT APPLICATION Office Use Only
Permit#: go°L - 8L197 - 9011
Town of Queensbury Permit Fee:$ /?S ; Invoice#:
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net Notes:
Project Location: 111 Fourth Street Queensbury NY 12804
Tax Map ID #: 9• I I — 1 " /3 Subdivision Name:
CONTACT INFORMATION: D [ 1 '1
• Applicant:
EU_L 1)
Name(s): Zacharia Nasr - C.)
Mailing Address, C/S/Z: 111 Fourth Street Queensbury NY 12804 TOWN OF QU: 'JS F
Cell Phone: ( 518-260-9223 ) Land Line: ( ) BUILDING& •+r'-5
Email: Zacharia.Nasr@outlook.com
• Primary Owner(s):
Name(s): Zacharia Elias Nasr
Mailing Address, C/S/Z: 111 Fourth Street Queensbury NY 12804
Cell Phone: ( 518-260-9223 ) Land Line: ( )
Email: Zacharia.Nasr@outlook.com
❑ Check if all work will be performed by homeowner only
• Installer/Builder: Workers' Comp documentation must be submitted with this application
Contact Name(s): David Barlow Owner Pools Pluse
Contractor Trade: Pool Installer
Mailing Address, C/S/Z: Click or tap here to enter text.
Cell Phone: ( ) Land Line: ( 518-793-2929 )
Email: www.mypoolsplus.com
**List all additional contractors on the back of this form
Contact Person for Building & Code Compliance:
Cell Phone: ( ) Land Line: ( )
Email: Click or tap here to enter text.
Swimming Pool Packet Revised February 2019
• Installer/Builder: Workers' Comp documentation must be submitted with this application
Contact Name(s): David Barlow Pools Plus
Contractor Trade: Pool Installer
Mailing Address, C/S/Z: 45 Main Street Queensbury NY 12804
Cell Phone: ( ) Land Line: ( 518-793-2929 )
Email: Click or tap here to enter text.
• 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: Click or tap here to enter text.
• Installer/Builder: Workers' Comp documentation must be submitted with this application
Contact Name(s): Click or tap here to enter text.
Contractor Trade: Click or tap here to enter text.
Mailing Address, C/S/Z: Click or tap here to enter text.
Cell Phone: ( ) Land Line: ( )
Email: Click or tap here to enter text.
• Installer/Builder: Workers' Comp documentation must be submitted with this application
Contact Name(s): Click or tap here to enter text.
Contractor Trade: Click or tap here to enter text.
Mailing Address, C/S/Z: Click or tap here to enter text.
Cell Phone: ( ) Land Line: ( )
Email: Click or tap here to enter text.
• Installer/Builder: Workers' Comp documentation must be submitted with this application
Contact Name(s): Click or tap here to enter text.
Contractor Trade: Click or tap here to enter text.
Mailing Address, C/S/Z: Click or tap here to enter text.
Cell Phone: ( ) Land Line: ( )
Email: Click or tap here to enter text.
Swimming Pool Packet Revised February 2019
V--
SWIMMING POOL INFORMATION:
CHECK ONE: ❑ABOVE- GROUND ®IN-GROUND
SIZE OF POOL: 18 by 36
MANUFACTURER:
MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY):
Steel/Vinyl ® Fiberglass ❑ Gunite ❑
Poured Concrete ® Other ❑ (Explain:
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: Zach ria E. Nasr
SIGNATURE: 1 DATE: 7/Z)
Swimming Pool Packet Revised February 2019