application CERTIFICATE OF OCCUPANCY ONLY Office Use Only
APPLICATION Permit#: CO — 0 l�0 * lc)
ate <a ccn.furi Permit Fee:$ (C)a
1.742 Bay Road,Queensbury,NY 12804 Invoice#: bb lP
P:518-761-8206 or 518-761-8205 www.queensbury.net
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**This application is for occupan t atificllvagr i ing a building permit**
CONTACT INFORMATION: APR 0 8 2019
TOWN OF QUEENSBURY
BUILDING&CODES
• Applicant: tf-
Name(s): CLLAJ tl 01 S
Mailing Address, C/S/Z: 5 p) 0
iA;� S ,�- ( uttot G try , ,i/. S u 4& 4.
Cell Phone: ( s) q, ) rZ2i , 2 v -� / - Land Line: ( S c, ) '�80,
Email: D
• Business Owner(s): �, A� p
Contact Name(s): U ftAl CocL Re (G4• 1�'foil' vu, J'1C.e�:�•�,•.t ( 1 - C•
Mailing Address, C/S/Z: 5 tiAzn S �.-, / Sri (3 iry ,y E (A
Cell Phone: _(5,) ZZ _ Q_ 6 � Land Line: _(5 I $ ) C� g alas
Email: v
e- La, k s oI ; l`'' �n�w�ai • to"
• Manager:
Contact Name(s): 0;AnJ'Ne fete S
Mailing Address, C/S/Z: -rin #tsr ST,Staito, IQt4EENs&iudzw., y,t/ /spot
Cell Phone: _( SIB ) 53 1-09L'9 Land Line: _( Sir )
Email: cattnneecc-rr?rC ivre-Le,i e1 c.•Net
• Property Owner(s): L C
Business Name: ive MM.,,. C �. j'� A `v.�..
Contact Name(s): (A 4 0 d S �•
Mailing Address, C/S/Z: 5 1e . s �. & , it/� 1 2 S t+ 4-
Cell Phone: _(5 8 ) �21 _ G Land Line: _( 5 ► Q ) "4_ \ e - 22 e s
Email: // rr
, 0.G `ucil f i LdTn^a: Q • C016",
Certificate of Occupancy Only Revised June 2017
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742 Bay Road,Queensbury,NY 12804
P:518-761-8206 or 518-761-8205 www.queensbury.net
BUSINESS INFORMATION:
Name of business: j 4-0,S Co.yr &, Re k G, G % 1 (I fJ i t"., J�1 eal Lt , p. C.
Address (including suite, space, etc.): 5 /m a�,,� , F IAt�nS L\c )
�I , 1240o (4 sue; c Cf.
Type of business (i.e.: retail, car repair, etc.): ! ►[ L c J
Please provide an accurate layout of your store showing all walls, exits, stockrooms, rest
rooms, counters and fixtures on a separate sheet of paper.
IMPORANT: The business owner is responsible for keeping exits clear and maintaining exit
signs and emergency lights. Fire extinguishers, fire sprinkler systems, and fire alarm systems
require annual inspections by an outside contractor and the corresponding documentation
must be provided to the Town of Queensbury Fire Marshal's office. Fire extinguishing systems
found in kitchens and gas stations require semi-annual inspections. Any violations noted
during an inspection require immediate corrective action and a re-inspection.
pp r/ b j 4 3
Applicant name: n, 1a
Applicant signature: r ®�
Date: (f I (+ I 0`
Certificate of Occupancy Only Revised June 2017
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fr at11 4'1°t ii¢4'fl+fuf'
742 Bay Road,Queensbury,NY 12804
P:518-761-8206 or 518-761-8205 www.queensbury.net
EMERGENCY CONTACT INFORMATION
**THIS FORM IS USED TO ASSIST EMERGENCY SERVICE PERSONNEL WHO MAY BE CALLED TO YOUR
BUSINESS AFTER HOURS. PLEASE BE SURE THE CONTACTS LISTED BELOW ARE WILLING AND
AVAILABLE TO REPSOND DURING OFF-HOURS TO ASSIST POLICE AND/OR FIRE PERSONNEL IN
GAINING ENTRY TO YOUR BUILDING.**
PLEASE BE ADVISED THAT FAILURE TO ASSIST EMERGENCY SERVICE PERSONNEL MAY RESULT IN
DAMAGE TO YOUR BUILDING BY POLICE AND/OR FIRE PERSONNEL.
Date: Et- / 1 r 1
Business Name: C �'V‘A —/ p .c.
Business Location (including suite, space,etc.): �j M 6.Z A .5 1- Qji _9 fly.S LA f y . /f y
29c4 s�-: � � 4 A, 6 /
Business Phone#: 5 " 2.22
1. Contact name: 40. 11
Main Phone:_(5 1 j ) - 222SSecondary Phone:_(5 I Qj ) 221 ^ g v 3-
Coming from what
town/village? C L 0. yyk , ci
2. Contact name: (UU\6 RAODKS
Main Phone:_( r )79k' ? ? " ; Secondary Phone:_( .�L!g ) 53 N: 0948
Coming from what town/village? So4'"N G I E$(s YAiUS
TOWN OF QUEENSBURY FIRE MARSHAL'S OFFICE
P: 51 8-7 61-8206 F: 518-745-4437
FIREMARSHAL@QUEENSBURY.NET
FIRE MARSHAL MIKE PALMER DEPUTY FIRE MARSHAL GARY STILLMAN
Certificate of Occupancy Only Revised June 2017