application SWIMMING POOL PERMIT APPLICATION Office Use Only
• CAD 1.-�b - 0 Z0
Permit#. Q •i
Town of Qeensbury Permit Fee:$1 ZS ;Invoice#: 210 5 6
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 w wu.queensburv.net Notes:
Project Location: t�••� LC vLt.
Tax Map ID#: del i 4 - — 3% Subdivision Name: �- c-ck- - oock C
CONTACT INFORMATION:
• Applicant:
Name(s): Nt icA,•�- 16 kv.bw ct.
Mailing Address, C/S/Z: a en‘Acx (r,awe '^sk'L-'-y Jj. ' . / I a. 6
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Cell Phone: ( ) a.3a- �� Z Land Line: ( s I11 ) - S
Email: inn d ok AAA w.CA.en q c j c w.a: V . C. w
• Primary Owner(s):
Na me(s): M`\.o.v\ 0Z s<k l�tv‘c,N w C( -
Mailing Address, C/S/Z: 0oc v t CO&OL LA.v.c ev sC* /I V. / l al'6t-i
Cell Phone:_( ) 3a -1 3Z Land Line: _( St g ) ? t -68 oc
Email: rn at �cw e v cf-s`. e . co ut,\
'Check 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:_( I
Email:
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Swimming Pool Packet Revised May 2020
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SWIMMING POOL INFORMATION:
CIRCLE ONE: ABOVE-GROUND IN-GROUND
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SIZE OF POOL: A rc c) ,�
MANUFACTURER: �. at woo c�
MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY):
Steel/Vinyl 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: M -L c Div L.nc�v�
SIGNATURE: 91DATE: (a 4 ( atsao
Swimming Pool Packet Revised May 2020