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SWIMMING POOL PERMIT APPLICATION Office Use Only permis.POOL -0222-202} Tom of Cucensiary permit Fee:§125_;invoice #:225} 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.queensbury.net Project Location:“Vota rdeow St.LY ecenshury Tax Map ID #:523 40D 309./b-2-S%___Subdivision Name: Notes: CONTACT INFORMATION: ©Applicant: Name(s):(32°lacodand Mailing Address,c/s/2:44-Lo/ndspag De-(CMucensia LV,(AGS Cell Phone:S12 )-Land Line:Wi wo emait_harh shasta @ hotma/+Com «Primary Owner(s): Name(s):S Mailing Address,C/s/z:__SPW ee Cell Phone:_()AS Abe’Land Line:_() Email:' O Check if all work will be performed by homeowner only *Installer/Builder:Workers’Comp documentation must be submitted with this application Contact Name(s):in Ball Contractor Trade:___Pao)Pande Mailing Address,C/S/Z:_2 A@Ayy Ay Sih.7 T [26 6s" Cell Phone:_(S/H)AS ~5E/57 Land Line:_() Email:Z **List all additional contractors on the back of this form Contact Person for Building &Code Compliance: Cell Phone:_(___) Email: ‘ |||may 28 2020 TOWN OF QUEENSBURYORDLBING‘&CODES: ‘Swimming Pool Packet Revised February 2019 SWIMMING POOL INFORMATION: CIRCLE ONE:ABOVE-GROUND wero» size oF Poot:_)Cx 32h MANUFACTURER:how FAS pipira MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY): Steel/Vinyl_“Fiberglass Gunite Poured Concrete Other Declaration:|acknowledge no construction activities shall be commenced prior to issuance ofavalidpermit. 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.|acknowledge that |have read the application and plot plan requirements and |,or my agents,will obtainacertificateofcompliancebeforeuse of the pool. Ihave read and agree to the above: PRINT NAME:“Naaes Bah SIGNATURE:A tM,Lal DATE:s/207 m Boll will tex his do eumentakonswepoo!SI8-145—F437. ‘Swimming Pool Packet Revised February 2019