application is
.Le',- _-.--: SWIMMING POOL PERMIT APPLICATION Office Use Only
, / ,, Permit#: POQ 14- Zb Z
Town of Qu cc.nsbury
Permit Fee:$ i2c7 :Invoice#: Z`l i S
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net Notes:
Project Location:2i PP r;5 C\re,1t,I AQAASbc,cJ N
y r V/ l�.\-(2Y
Tax Map ID#: S23%'0o 1. —/-1. 1f Subdivision Name:slit T hrliAl ESi-. ..
CONTACT INFORMATION:
• Applicant: 1
Name(s): 0� IC Cg\--,N JU
Mailing Address, C/S/Z: 'LI 6Qpr , C1c6\/ , $& e,Y lu D-(
Cell Phone: (5 ' ) 337- 4I l Land Line: ( �/ '. 0
Email: Ec,e- 111-7 ® iiSiv - "?'"`-) _
• Primary Owner(s):
Name(s): r`-),q„c r P, --i- iv)c cku J U
Mailing Address, C/S/Z: Sc .
Cell Phone: _( ) 5c. Land Line: _( ) S c r"$ .
Email: 3 c
0 Check if all work will be performed by homeowner only
• Installer/Builder: Workers' Comp cumentation must be submitted with this application
Contact Name(s): ii7 .1G.Q.\ d3C-v..eAr c.'e. Adis F
Contractor Trade: C'T,,,--li csc ,c—
Mailing Address, C/S/Z: Oe Bottenc477 S1.4 ' I, l� - �c i 4- /1' /rj-ja�
Cell Phone:_(.mod Z- ) Sol-C Land Line: (.c7 t ) 7 tl7 P 2X
Email: < ;P rG ea 1--Pasta ® Ou-1--1�o . ^� i
**List all additional Contractors on the back of this form it -7-)
W
a co_ 8I se
Contact Person foK Building & Code Compliance: /21<,J2 ad / ( A 1== V l
Cell Phone: 6-i ) 202-41 � La d Line: ( ,fr ) A . (�'
Email: r-c S es) '/a OtAo\c . �.." t_ u-
L c�
OR. 'om
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73Ct_rk t v- ,
Swimming Pool Packet Revised May 2020
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SWIMMING POOL INFORMATION:
CIRCLE ONE: ABOVE-GROUND IN-GROUND
SIZE OF POOL: / JC ,C
MANUFACTURER: S pC t� ���
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: 73a / ��\"--2 r&-,
SIGNATURE: 01_9r. "--
DATE: 'W2-F/
f
Swimming Pool Packet Revised May 2020