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application SWIMMING POOL PERMIT APPLICATION Office Use Only Permit#: ?OW__ " OJ��- 2-0 11 Town of Queensbury Permit Fee:$ 2-5 ;Invoice#: 151"4-- 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.queensbury.net Notes: Project Location: 34 Western Reserve Trail, Queensbury Tax Map ID #: Click or tap here to enter text. Subdivision Name: Click or tap here to enter text. CONTACT INFORMATION: • Applicant: FifGEOWE ')'\ Name(s): Mickey Orta Mailing Address, C/S/Z: 34 Western Reserve Trail I �► MAY 3 0 2015 U !; Cell Phone: (518-932-1709 ) Land Line: ( ) I Email: mickeyorta@gmail.com TOWN OF QUEENSBURY BUILDING&CODES • Primary Owner(s): Name(s): Mickey and Maggie Orta Mailing Address, C/S/Z: 34 Western Reserve Trail Cell Phone: (518-932-1709 ) Land Line: ( ) Email: mickeyorta@gmail.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): Pool Plus 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: ( ) - ',a 9 Email: Click or tap here to enter text. **List all additional contractors on the back of this form Contact Person for Building & Code Compliance: 2 ' 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): Click or tap here to enter text. •245 ?a-5 Contractor Trade: Click or tap here to enter text. Mailing Address, C/S/Z: Click or tap here to enter text. 7f3 r 09d g Cell Phone: ( ) Land Line: ( ) 9 Email: Click or tap here to enter text. VC/V4'11 SDf, / m01 • 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. • 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 J R SWIMMING POOL INFORMATION: CHECK ONE: ❑ABOVE- GROUND ©IN-GROUND SIZE OF POOL: 16x32 MANUFACTURER: Pools Plus MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY): Steel/VinyV Fiberglass ❑ Gunite ❑ Poured Concrete 'e 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: Mickey Orta SIGNATURE: Click or tap here to enter text. DATE: Click or tap here to enter text. .3-lcs/y /1 Swimming Pool Packet Revised February 2019