application SWIMMING POOL PERMIT APPLICATION Office Use Only
JL� lb L� � V 15 Permit#: �Vo L `v,S y�" �l
(Z�Town of ccnsbury D
Permit Fee: $ 1Z5 ;invoice#: / t /0
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensburv.net SEP 0 3 2019 Notes:
•
TOWN OF QUEENSBURY
Project Location: (; (`(�t4 , �'��%a'1�Yv:�UING&CODES
Tax Map ID#: ✓`y&E 13 - 1-;1(3 3-- Subdivision Name:
CONTACT INFORMATION:
• Applicant:
Name(s): John 'k Sarah IA) c nt
Mailing Address, C/S/Z: t-jD CAfS--erS Oren n 1�,,i.t.���g�ni.r �y� I- ;
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Cell Phone: ( SIP) ) 3cr (197Sa Land Line: ( )
Email: joy\. �.;��i h{ (O( c r^- tU L0,Y1 ) J du) G) bfsrtai.uur Cow
• Primary Owner(s): i
Name(s): See NNCeo+ ic-(
Mailing Address, C/S/Z'`.
Cell Phone: _( ) Land Line: _(
Email:
0 Check if all work will be performed by homeowner only
• Installer/Builder: Workers' Comp documentation must be submitted with this application
Contact Name(s): Vac PILLS I Da iL 4ft r Jv i )
Contractor Trade: ool Li1S AtI
Mailing Address, C/S/Z: '-S N'atn ,C5bi
Cell Phone: _(-5l99 ) �i SS - JISU Land Line: _( Si'3 ) 7 f 3 aqo q
Email: my pot)) lls O;iahoo. (t,m
**List all additional contractors on the back of this form
Contact Person for Building & Code Compliance: ,.chn r t i rt—
Cel l Phone: _( S 1� ) _:30 - ( )S 5 Land Line: _( )
Email: )C,�u 7f ITS( \CLtjj • ( o
Swimming Pool Packet Revised February 2019
• Installer/Builder: Workers' Comp documentation must be submitted with this application
Contact Name(s): 44 roan Sa Cc cx-Ji
Contractor Trade: ' c -t>k-C_
Mailing Address, C/S/Z: 37a? Al 54('YJr- R f d LP r N/ t 35
CeII Phone: _(5(}- )�7�'fo - 1108 Land Line? _( Sig ) -a55(
Email:
• Installer/Builder: Workers' Comp documentation must be submitted with this application
Contact Name(s): S -}7C\ �tlCQ / �t11 ' 01-1)(
Contractor Trade:
Mailing Address, C/S/Z: �I 1 Crc •L L gCX') etti ivy
Cell Phone: _(5 ) (p3(l - (195(f Land Line: _(,5/ ) 79c)-SIN 7
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
SWIMMING POOL INFORMATION:
CIRCLE ONE: ABOVE- GROUND IN-GROUND
SIZE OF POOL: (= U 3
MANUFACTURER: 1 mpQv1),
MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY):
Steel/Vinyl X 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: � n L.1.) C 1 (( I'1i'
SIGNATURE: DATE: I
^ P
Swimming Pool Packet Revised February 2019