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SWIMMING POOL PERMIT APPLICATION Office Use Only
Permit#: ,ptvL- 0 c.� Lts--�l /
Town of Qucensbu n a ►� E ZS/� 7 9Z
742 Bay Road,Queensbury, NY 12804
D E E o \J�n �, Permit Fee:$ l Invoice#: Y
P: 518-761-8256 www.queensbury.net Notes:
I [ JUN272319Li
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Project Location: OGJE V TOWN OF CU[=i:.NSBU,R.v j
_ *NG & ^0 ter-:
Tax Map ID #: �ctS , IQ -3 �-74 Subdivision Name:
CONTACT INFORMATION:
• Applicant:
Name(s): 13R. V(E PcOL,1L
Mailing Address, C/S/Z: /9 Ow6N Avg 61VcdNS Bogy Ny /:2(jiL1
Cell Phone: ( SI$ ) .2 - 9S27 Land Line: ( ) N/A
Email: pooler SR ® YAHdo . CO
• Primary Owner(s):
Name(s): 6,QvCC + 111A1Z6rA PooL62
Mailing Address, C/S/Z: /9 ow. 't' Ave: at�IE.L�►SISJAy Ny /210s/
Cell Phone: _( S Y ) 222 - 95-.27 Land Line: _( ) Allif
Email: Pey)let S.3 d YA1Iiv , Coin
El Check if all work will be performed by homeowner only
• Installer/Builder: Workers' Comp documentation must be submitted with this application
Contact Name(s): Pools Pt vs (Olive f- 54NDA4 84 Low )
Contractor Trade: Poo/ .rrvSrlttCR
Mailing Address, C/S/Z: NS MAIM Sri/66r 6ve.e- v2V NV /) t V
Cell Phone: _( ) N/A Land Line: _( rig ) 793- a9 21
Email: MYPoots_Pw56 y4Bcv con,
**List all additional contractors on the back of this form
Contact Person for Building & Code Compliance: ,41DS Ptv' (Oi.vi 6netow
Cell Phone: ( ) Al�,4 Land Line: ( cog ) 793 * 212f
Email: /iypoolsPL,JS6) V,4ui .coin
Swimming Pool Packet Revised February 2019
SWIMMING POOL INFORMATION:
CIRCLE ONE: ABOVE- GROUND IN-GROUND)
SIZE OF POOL: IL r x 3 Z
MANUFACTURER: P ' rn N L'm P6015
MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY):
Steel/Vinyl X Fiberglass Gunite Poured Concrete x Other A
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: 13I2Ucc PocLEIZ
SIGNATURE: DATE: 4-.27-J9
Swimming Pool Packet Revised February 2019