application Town of Queensbury Building & Codes Office Use Only
Received:
SWIMMING POOL PERMIT APPLICATION Tax Map ID:
A permit must be obtained before beginning construction P6O G 3 31/ -d-o / 9
Permit No.:
Permit Fee: $ ii.�6��
ISite PlanNariance No.:
1. Date: r-Lis - I ck ._r.a, _�®.____� ,__
2. Tax Map ID: 2 ,1 c--I - Ia L-� `i l! ,y� L_� i1�9
IN 1
3. Pool Location Address: 51 "' . 3 /fi`:3 i°¢
C�{L.h,�a�v �R t�,G I II .4 g, �A,r l
4. Zoning Classification. 4i ' . P'\ ii- PLf. TCr 5 J �pi k L�. 3 �rl�f U s ,
5. Site Plan Review,Variance or Subdivision Approvals(list)
6. Property Owner: 5TA Ljk,( Ca 31-7 (v..iiciA Phone: S I ' 3 2-1. 4 4''
Mailing Address: 4-3 Fv.,,., i .
City: Cp0�-1,- 190 >i i av,`t 12-'r----
7. Contractor's Name: C 01'J _c PDD LS Phone: cI 7-7 73 • V9 sl-.
Mailing Address: I C(-- 5'PP(th-,)?s.-,63 JS l-E (Z�
City: t Pr'l-rt.\r(A_ I1\--S - ) 2-k )U" A 0 nc-1 I+T
5-Igz° ,)' el521
8. Contact Person for Building&Code Compliance: "Tc v-t Pr LtiL iiT Phone
ABOVE-GROUND OR INGROUND? I Cti32-6-‘5>
SIZE OF POOL: 6' X 14
MANUFACTURER: C o)0 0 IJ Poe)(---
MATERIALS USED IN CONSTRUCTION(CHECK ALL THAT APPLY):
Steel/Vinyl ✓ Fiberglass Gunite Poured Concrete 7 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 NY State Building Codes, local building laws and ordinances, and in conformance with local zoning regulations. I
acknowledge that I have read the application&plot plan requirements and I or my agents will obtain a certificate of occupancy before use
of the pool.
Print Name: �� ( . 3 --1- g
Signature: a Date 51 L, t t
Name/ '
Town of Queensbury Building&Codes Swimming Pool Permit 518-761-8256