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SWIMMING POOL PERMIT APPLICATION Use Only
permit #POOL NL¥S-2029
Town of Queensbury Permit Fee:$125>_;invoice #:22
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net
Project Location:/Zb P24 EREC Wi?CEECR.yr,~
Tax Map ID #:Subdivision Name:
Notes:
CONTACT INFORMATION:
.licant:
Name(s):AicHaR«a L702 07L
Mailing Address,C/S/Z:6 “22 OEZRS WPAY @y¢lnsAuRy AA
Cell Phone:($7@_)440/-7272 landline:(2707)459-7256
Email:
°Primary Owner(s):
Name(s):AeCHPRO SODAIL
Malig Nios,(67 2q¢p)AB AS PAY QAEEVSBY,1 2-B<e
Cell Phone:_(S7@ )$2/-227.landline:(370 )4o¥F756
Email:
O Check if all work will be performed by homeowner only
Installer/Builder:Workers’Comp documentation must be submitted with this applicationcontactName(s)Baginw Pape Tac dba Dysto Owo
Contractor Trade:_Cuotrn Pa Por bd 9X5 |
Mailing Address,ose YS Warn GF Oseeno bura7 Ny TOM
Cell Phone:_(landline:(Six)292 —A9Q4Email:DEKE plus m0 ala pp.Cann
**List all additional contractors on the back of this form
[RECEIVE |Contact Person for Building &Code Compliance:
Cell Phone:_()Land Line:JUN uecaEmail:
‘Swimming Pool Packet Revised May 2020
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SWIMMING POOL INFORMATION:
CIRCLE ONE:ABOVE-GROUND IN-GROUND
size or Poot:JAXAyPAX3LUyPou
OreperiadPostoMATERIALSUSEDINCONSTRUCTION(CHECK ALL THAT APPLY):
Steel/Vinyl_/Fiberglass Gunite Poured Concrete Other
MANUFACTURER:
Declaration:|acknowledge no construction activities shall be commenced prior to issuance of a valid permit.
|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 obtain a certificate of compliance before use
of the pool.
Ihave read and agree to the above:
PRINT NAME:
DATE:2,2DSIGNATURE:
‘Swimming Pool Packet Revised May 2020