application CERTIFICATE OF OCCUPANCY ONLY Office Use Only
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AP ' 'r ',‘ i Permit#: CO—0S —5—°19
louts,r(j,nc,,,hun L E l ll h I Permit Fee:$ 1 U C) ' b
742 Bay Road,Queensbury, NY 12804 AUG 19 Invoice#: I t
P:518-761-8206 or 518-761-8205 www.• ee •ur .net 2U19
TOWN OF QUEENSBURY
BUILDING& CODFS
**This application is for occupancy onTy`,W1ttrno-wor requiring a building permit**
CONTACT INFORMATION:
• Applicant:
Name(s): S ►u p i Al G a-44-1,
Mailing Address, C/S/Z: 9 5j (1Z ac 9 5„,44- lii
Cell Phone: ( q-1 ) 1-794 0 5-4 Land Line: ( 5 ► 1 ) 5/8 V.35 S.
Email: n/u.G.c:. 3 . 3 }06 ti—fatl -l'v'•1
• Business Owner(s):
Contact Name(s): Su Pin/4
Mailing Address, C/S/Z: l5 5 GL,i. 9 0 ....-,371,
Cell Phone: _(?-/g )S 59 ` _o S6 Land Line: _( )
Email:
• Manager:
Contact Name(s): 5,./4 q c.f..t.eAta
Mailing Address, C/S/Z: 1 g -i-n , , P/rc_ C7,«o,,..di,ce/l, .07 ( •z f 054.
Cell Phone: _( ')-13 ) 6-r,7/0 5-‘ Land Line: _( )
Email:
• Property Owner(s):
Business Name: (Z r./ 5 04 •') /..Z D m
Contact Name(s): 4 A/ D p E LY/ L AAk ,_,-
Mailing Address, C/S/Z: 1 S j 2„ 62 ce#,Jiaii j DU/ 11 re' i
Cell Phone: _( J f $ ) a 5 3 e/ .2_6' Land Line. _( )
Email:
Contact Person for Building & Code Compliance:
Cell Phone: ( PPS ) --9 6 x z G 2- Land Line: ( )
Email: AA/pastxr LARK's0' Q-Q--e.w% .ele.v„../4.�r-/I^. e„.
Certificate of Occupancy Only Revised December 2017
1,n,n 4,1(jurenfwn
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:
Business Name: 73-2 /,09-4J S P
Business Location (including suite, space,etc.): 95-9 kofic5 S' {.2(/
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Business Phone#: 5 l a c5 o b 3 5
1. Contact name: 1-1.," C -41
Main Phone:_( ?-t 2r ) S Ty 40 , ; Secondary Phone:_(
Coming from what town/village?
2. Contact name: l3'f �av A t.�
Main Phone:_( S I )' ) 02 5 o ; Secondary Phone:_(
Coming from what town/village?
TOWN OF QUEENSBURY FIRE MARSHAL'S OFFICE
P: 518-761-8206 F: 518-745-4437
FIREMARSHAL@QUEENSBURY.NET
FIRE MARSHAL MIKE PALMER DEPUTY FIRE MARSHAL GARY STILLMAN
Certificate of Occupancy Only Revised December 2017
flm❑44(Zmvn4btu
742 Bay Road,Queensbury,NY 12804
P:518-761-8206 or 518-761-8205 www.queensbury.net
BUSINESS INFORMATION:
Name of business: ti pa
Address (including suite, space, etc.): .544.44 VC/
9 59 j-c y $�.1y4 uv c,�,u�.,.,� nJy ( fd�
Type of business (i.e.: retail, car repair, etc.): geJ _ S p 4
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.
Applicant name: $I) P C--eve,Ka_
Applicant signature: ( p/A(0.7...
Date: o Y. i 9• / 9
Certificate of Occupancy Only Revised December 2017