application 4ito
SWIMMING PO_OLPERMIT-APPATIMN Office Use J0 Only
V
Permit#: PG'4- —ds7O —ZO/ /q
Town of Queensbury D Permit Fee: I V�nvoice#: /
742 Bay Road,Queensbury,NY 12804 JUL 3 0 2019 $ 1 Ks
P:518-761-8256 www.queensbury.net
TOWN OF OUEENSBURY Notes:
BUILDINGCODES
Project Location: -\' J\J cc --DG ;,,s, d_
y
Tax Map ID #: SCR, I v - z —3 S Subdivision Name: I-kcr-ciA
CONTACT INFORMATION:
• Applicant:
Name(s): 41 %,, .;-I
Mailing Address, C/S/Z: CI , ,',: ({,; �\4_,-e-• 6)61 i2SOc(
Cell Phone: ( `)\i, ) a .:).-)2,, Land Line: ( — )
Email: ,,%-kisc;: t \I'`) (4., ,hxi ccm,
• Primary Owner(s):
Name(s):
Mailing Address, C/S/Z:
Cell Phone: _( ) j' Land Line: _( )
Email:
O Check if all work will be performed by homeowner only
• Installer/Builder: Workers' Comp documentation must be submitted with this application
Contact Name(s): a-6 , -lp:,Yv-id y c"A'
Contractor Trade: Of,: \ ,^SVii Lvt.,.T.
Mailing Address, C/S/Z: ?00 BroeLdWa y, cUik L trf i.W& rd
Cell Phone: _( ) Land Line: _(.S/& ) '71-/7 9a'70
Email: Spr(.7. kUp 068 0 QUf/,/i'i9AIC.Dffi
**List alradditional contractors on the back of this form
Contact Person for Building & Code Compliance:
Cell Phone: ( ) Land Line: ( )
Email:
Swimming Pool Packet Revised February 2019
SWIMMING POOL INFORMATION:
CIRCLE ONE: ABOVE- GROUND N-GROUN
SIZE OF POOL: ( 2 v aL4
MANUFACTURER: ZrMQtr+ et . Po 0 L
MATERIALS USED INCONSTRUCTION (CHECK ALL THAT APPLY):
Steel/Vinyl V 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: - inc“`Gt ?S
SIGNATURE: Cc.t C AQ, DATE: (D- --lcj'
1.
Swimming Pool Packet Revised February 2019