application 4
SWIMMING POOL PERMIT APPLICATION Office Use Only
Permit#: �QL- b
Town of Qucensbury Permit Fee:$ ;Invoice#:
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net Notes:
Project Location: 7 /"/CId v/ecJ 49oar/ -5-U1.1 4/1
Tax Map ID #: u / . / a� - I 7. .3 Subdivision Name: 8oy/ eiy /ilECEOW/ E7,'
4UI Js
CONTACT INFORMATION: JUL 22 2020
• Applicant:
OF
Name(s): v/ 1 r TO UNLD G&CODES QUEENSBURY
Mailing Address, C/S/Z: u Ben s 6u /vetJ ye✓fC / ago
Cell Phone: (S/8 ) 79/_ / 2 a Land Line: ( •S 8/ ) 7 13 - I/ / 4/
Email: /') anCy Jynn v AD-E rrla.1 I ' Cows,
• Primary Owner(s):
Name(s): 7gsan + Na n e Vji o n der
Mailing Address, C/S/Z: Q u eP ) 4 L u V N y. /a 8 0 '
Cell Phone:_( _5/8 ) 79 1- / aa8 y / Land Line: _(.Si8 ) 7 `/3 - /// '/
Email: /fancy /y„n ./ C1 /o-E re)ar I ' COrv►
.i 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:2 I3Or)J AJaney V1 fancier
Cell Phone: ( 57 g ) 79/42,A 8 Land Line: _(.S/8 ) /7 4 3 //i `(-
Email:rtanCy /y,inv a Ao-Emu+l - eow)
Swimming Pool Packet Revised May 2020
SWIMMING POOL INFORMATION:
CIRCLE ONE: ABOVE- GROUND IN-GROUND
/
SIZE OF POOL: / X l� X
MANUFACTURER: i /'1 -tea(
MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY):
Steel/Vinyl V 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:N4SOn V I'a nder AlcLOC 11,1anc/e(
SIGNATURE: ' u DATE: 7 (a 1/ O�
Swimming Pool Packet Revised May 2020