application SWIMMING POOL PERMIT--APPLUC` ! ` e ice Use only
1,:rmit#:
Town of Osiccn'bury 1741
1
JUN 2 7 2019 ':rmit Fee:$1 ±; invoice#:
742 Bay Road,Queensbury,NY 12804
P: 518-761-8256 www.queensbury.net TOWN U1=QUEENSBUR tes:
// COMMUNITY DEVELOPMENT
Project Location: 302.3 Ac.3 e /Qi
Tax Map ID #: 303 5 --( - (L 1 Subdivision Name: /4
CONTACT INFORMATION:
• Applicant: J katv15/1a-a<er'
Name(s): % es l`"
Mailing Address, C/S/Z: 3a3 /e/�t ,4a 1,C�c'�-W?4,C� 1J f�.s�o'/
Cell Phone: (s/ � ) 79/ — yl Land Line: ( )
l
Email: QGzctl./y s' eu /S. Y t qr»a /
• Primary Owner(s): / //
Name(s): 9- f,?d / /7/`� a✓rl`siztuSe/
Mailing Address, CrS/Z: %/.l P A2d
Cell Phone: _( 57 r ) 7$ /- ADO f `� Land Line: _(
Email: Qc/aid //`Cn /CY Q 9/rut/1- Gc i
'eck 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:
Cell Phone: ( ) Land Line: _(
Email:
Swimming Pool Packet Revised February 2019
SWIMMING POOL INFORMATION:
CIRCLE ONE: ABOVE- GROUND IN-GROUND
SIZE OF POOL:
MANUFACTURER: y0)- L/L?60
MATERIALS USED IN CONSTRUCTION (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: e--;"c‘ 1pethf1nu(-te--
SIGNATURE: DATE: �� 7/ 9
Swimming Pool Packet Revised February 2019
J