POOL-0534-2020 pint
SWIMMING POOL PERMIT APPLICATION office use Only
�•�` v Permit#:10QR_."CO5 2012p
Town of Queensbury Permit Fee:$ 125 ';Invoice#:2C15.3
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensburv.net Notes:
Project Location: .;f434_ P1J errtishwy,i y i7-$j-
Tax Map ID#: 12Ale. Subdivision Name: 41,45 ors ee""0/01/
r) a7,7 re I] 'cur E.-. -)[-\
CONTACT INFORMATION: nri [ PO202Ol
• Applicant: TOWN OF QUEENSBURY
Name(s): /4/.a S. Cwr`/1e...4-ej/ BUILDING&CODES._
Mailing Address, C/S/Z: 6 ,r54.r.,/efie PA, eafee.`.shw,✓1
Cell Phone: ) 7 96= a 77-7 Land Line: ( / )
Email: �Ctr/ ie.. /7C >/b .t,r coon
• Primary Owner(s):
Name(s): A., w 5.
Mailing Address, C/S/Z: 6 r.i•4ft / 7� �Zu yea s�•../i� /4".4 / -24,1/
Cell Phone: _( i ) 7 96. 277 7 Land Line: _(
Email: 4 fp;c /7( 4.. ,"i IA cog..?
❑ Check if all work will be performed by homeowner only
• Installer/Builder: Workers' Comp documentation must be submitted with this application
Contact Name(s): �y�pr�s-s Poo S , f a (- H to
Contractor Trade: Feel. ri4 real%1'...,
Mailing Address, C/S/Z: //5 Gda de_ Qcl /et 74ha..9 //7 /e2.//p
Cell Phone: _( ) Land Line: (5l8 ) 773 — 5-423a
Email: press pool s® f/Cn0 . ✓r. �n1.1
**List all additional contractors on the back of this form
Contact Person for Building & Code Compliance: /}i7 a e,rpe,"3w
Cell Phone: ( 5/1 ) 7M-A7.7 7 Land Line: (
Email: c rp►G /7 es) abwrow'/ c.0641
Swimming Pool Packet Revised February 2019
• • Installer/Builder: Workers' Comp documentation must be submitted with this application
Contact Name(s): eo/a•�, /�f�riG Tcre/ 4,4461
Contractor Trade:
Mailing Address, C/S/Z: a ,5446s %er ie 7L �o/s4.,r4O/ ,t/:
Cell Phone:_( ) Land Line: _( .5�/.? ) 76'/- 3075
Email:
• 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:
• 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:
•
• 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:
• 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:
Swimming Pool Packet Revised February 2019
SWIMMING POOL INFORMATION:
CIRCLE ONE: ABOVE- GROUND IN-GROU
SIZE OF POOL: oN 'X 90
MANUFACTURER: `e %cl/ Ecl,`,LW,107 Pmol
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: , 9,7�,,iG..✓ S �lo•.s�®r,� �r.�
SIGNATURE: DATE: 7 3�2C36
Swimming Pool Packet Revised February 2019