application 1011 '
SWIMMING POOL PERMIT APPLICATION Office Use Only
•; Permit#:
Iinvn of Queensbury
Permit Fee:$ 12-5 ;Invoice#: 2 �
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensburv.net Notes:
Project Location: Att.
Tax Map ID#: '50 2. 6 �J r I�.1 Subdivision Name: /V r
CONTACT INFORMATION:
• Applicant:
Name(s): L-Art'ij
Mailing Address, C/S/Z: l! . ' Oldt, 12& , 0,I ch y _ /U,Y I cx 4•:
Cell Phone: .( 5%? ) 5- Land Line: .( )
Email: inrryhrrx,.n7 t tovh.
• Primar Owners
Name(s):
Mailing Address,C/S/Z: 0,I61 'r(m�p1 i?'f ., uz46c4.tt. h, V ja 4
Cell Phone:_( 5/i' ) 762 `itrceK. Land Line: i( )
Email: faer.iib:0-:N7 c6 l4.ce,-
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: ( )
Email:
•
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Swimming Pool Packet Revised May 2020
q ; i 7:
SWIMMING POOL INFORMATION:
CIRCLE ONE: ABOVE-GROUND ` IN-GROUND
SIZE OF POOL: / P�
MANUFACTURER: J ( iGl,lcI;11z
MATERIALS USED IN CONSTRUCTION(CHECK ALL THAT APPLY):
Steel/Vinyl ✓ Fiberglass Gunite Poured Concrete Other V
eca IS `. aA x I) ki-26
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: e( V
SIGNATURE: ,[ DATE: (O , :14h
CS
Swimming Pool Packet Revised May 2020