application SWIMMING POOL PERMIT APPLICATION Office Use Only
Permit#: �O�t a 1 g21Qy* ?J.1i1.el
Town of Queensbury Permit Fee:$ 12.L" ,r ; Invoice#: t e;.o
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net Notes:
Project Location: -76¢ 140e0o.c ¢ A4chA -y
Tax Map ID #: 30l gO I; 3n . 1 Subdivision Name: n
APR 0b 2019
CONTACT INFORMATION: TOWN OF OUEENSBURY
BUILDING&CODES
• Applicant:
Name(s): e c y i4vtc—omb.
Mailing Address, C/S/Z: j-(�,,� �-d"L $ -cv_t�. Q�.t e � � �;.i 1 g0 /
Cell Phone: (Si ) g3.2 - '7o0 3 Land Line: (
Email: ,..reb.ttc.ipre‘%3 ) t'Qyn&c�.,c,S t-e)rrl
• Primary Owner(s):
Name(s): �-��c-Cx� VA cal t�m�
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _(
Email:
Check if all work will be performed by homeowner only
• 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:
**List all additional contractors on the back of this form
Contact Person for Building & Code Compliance: �p\ic�n-r'T
Cell Phone: ( ) Land Line: ( )
Email:
Swimming Pool Packet Revised February 2019
SWIMMING POOL INFORMATION:
CIRCLE ONE: ABOVE- GROUND_) IN-GROUND
SIZE OF POOL: /
MANUFACTURER: L OI t ke.3 c4kQ..
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: -e.(C--ey ,,rt
SIGNATURE: 4l4_(.4,
91154-0744.-6"" DATE: a - �, . i - vi9
Swimming Pool Packet Revised February 2019