POOL-0175-2020SWIMMING POOL PERMIT APPLICATION.[oficuse
permit POOL 0175-2ove
nrg Permit Fee:$AAS;invoice 29.29
742 Bey Road,Queensbury MY 12808 wot
|PrSM76L4256 wonw.queensbon.net ssProjetcation:34Noshavsd.
‘Tktaxmopwe:__288.1h-|-5.subdivision name:
(oudttouee
Golakes
CONTACT INFORMATION:
+Applicant:
Name(s):Golleen
Maling Address,c/57
cellphone:_(91$)34-43
9
Land tne w
Email:
‘+Primary Owner(s):
Name(s):
O cheek if all work will be performed by homeowner only
+Installer/Builder:Workers’Comp documentation must be submitted with this application
Contact Name(s):Consort fools
Contractor Trade:
Malling Address,C/S/2:dwfiy $
Cell Phone:_(tan tine:_(
S¢9)_"984 =
Email:contend pi Bryan@Aalto**List all additional contractors én the back of this form
Contact Person for Building &Code Compliance:‘Amboro
Cell Phone:(_)Land Tne 5180 aEmailHontordP00Bryan@d0|-tom_
‘SWIMMING POOL INFORMATION:
concie oe ‘ABOVE:GROUND
swe or roo:9%3
(MANUFACTURER:
[MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY):
steeyinyi_X Fiberglass Gunite Poured Concrete other
Declaration:|acknowledge no construction activities shall be commenced prior to issuance of 8 valid permit.|certify that the application,plans and supporting materials are a true and complete statement/description of
the work proposed,that all work wil 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,wil obtain a certificate of compliance before use
of the pool.
‘have read and agree tothe above:
or NAME Collen,Havedly
SiGnaTURE:Cod.Hava are:4-84-20
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MICHAEL DICKINSON
92 aay srecer TOWN OF QUEENSBURY,WABEEM CONTI,NEW OC
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