application Office Use Only
Town of Queensbury Building & Codes
Received:
SWIMMING POOL PERMIT APPLICATION Tax Map ID:
A permit must be obtained before beginning construction Permit No.: �ac.� '2020
Permit Fee: $ L-GJ
Sii�f�lan/V Ilan�eidu.:�Y�W�v.S 2.8 2-2
1. Date: 4/c23
2. Tax Map ID: 3D!. 5- 1 -33
3. Pool Location Address: ) D un'Ir)S L c nE'
4. Zoning Classification:
5. Site Plan Review,Variance or Subdivision Approvals(list)
6. Property Owner: J(zn e j, G c rd:n e r Phone: al O`J
Mailing Address: 11� �j u C r n Sl-a n e
City: R o-en5bL'f Ni -t J( O 71
7. Contractor's Name: Spr7 t_tt c Cr-Ci VG &f c h)Phone: _51 U V
Mailing Address: , Po Kr1X? 1, / S t 4 I
City: krt E G�arct-3NV J;Di g
1
8. Contact Person for Building&Code Compliance: Phone
ABOVE-GROUND OR INGROUND? I ng ro n
SIZE OF POOL: c.Q0 V 3J-1
MANUFACTURER: JUL 23 2020 ' LJ
MATERIALS USED IN CONSTRUCTION (CHECK ALL THAT APPLY): Y
TOWN OF QUEENSBUr
Steel/Vinyl ✓ Fiberglass Gunite Poured Concrete ✓ Other
BUILDING&CODES
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 NY State Building Codes, local building laws and ordinances, and in conformance with local zoning regulations. I
acknowledge that I have read the application &plot plan requirements and I or my agents will obtain a certificate of occupancy before use
of the pool.
Print Name: Jane_ t3 , V-a rd r,P r
Signature: C do r a n r Date T/;3),90
Name tle
Town of Queensbury Building&Codes Swimming Pool Permit 518-761-8256