application SWIMMING POOL PERMIT APPLICATION Office Use Only
Permit#: ND 1 0
Town of Quecnsbury
Permit Fee:$ 125 :Invoice#: t"1
.,� 742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net Notes:
Project Location:3/ Oeckeir-A)OoU br.
Tax Map ID#: Subdivision Name:
CONTACT INFORMATION:
• Applicant:
Name(s): 7-611rlsoY1 -i- 0w5indr& OThnre(/
Mailing Address,C/S/Z: 3 I Ceday (,)Ood (PtLf e,y1bbu rV
Cell Phone: (5/. ) 0a_5 Land Line: ( is ) -1 ga-Ok3 1
Email: 7 f'Ylr/yO tt b'?Db G' Jaivod . CO1 v1
r
• Primary Owner(s): /v - I
Name(s): �YevldeSH 4- C ,a 55 G�-�'lC�� - O DO v1 Viet
Mailing Address, C/S/Z: 31 Cedc rtUoc d -Dr • u env, ,q
Cell Pho�e:_(61 FS ) �- / a_6 Land Line: _( 6 lsFS" )
Email:+t irn i OP b I(/(Sv c . CDWt
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 fi i ]Via /Pa ���C' 1 10..SeheX
Contractor Trade: 1'C! 1te/-
Mailing Address, C/S/Z: _c) ,6.z rp_a`-1 J u l I O
Cell Phone:_(, Ir ) q6 q-/6 c1 Land Line: _(
Email:etripi -e. DO/Savicl,4 iniarriS mai rn l . Qo
**List all additional contractors onihe back of this form
Contact Person for Building & Code Compliance:
Cell Phone: ( ) Land Line: (
Email:
JUN 29 2020
TOWN OF QUEENSBURY
BUILDING&CODES
Swimming Pool Packet Revised May 2020
pt
SWIMMING POOL INFORMATION:
.1'
• CIRCLE ONE: ABOVE- GROUND IN-GROUND
SIZE OF POOL: c26"/ P4-
MANUFACTURER: -+1cm- l`e.. POOLS
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 ag�the ridohO / o'irj/
PRINT NAME: 0-os.saric)ra_. 0 �4J O n ne 1 '
SIGNATURE: 0ClgtrYVALV.-0 DATE: (12/11 J ol0
Swimming Pool Packet Revised May 2020