application CERTIFICATE OF OCCUPANCY ONLY Office Use Only
,40111
`- rJ APPLICATION Permit#: CSJ ` O b co co •
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b.:,„r c Permit Fee:$ CC)
742 Bay Road,Queensbury,NY 12804 Invoice#: ZO(.c2:1-
P:518-761-8206 or 518-761-8205 www.queensbury.net
**This application is for occupancy only, with no work requiring a building permit**
CONTACT INFORMATION:
• Applicant: ``
Name(s): ` 11.� �� `�L.C-4 r
Mailing Address, C/S/Z: Lj c ,�-Q, ((�}�
Cell Phone: (Ez l ‘ ) `�Z2 Land ine: (
Email: 1,1-4 QC Q c 7 Q804(6 d JL-L
• Business Owner(s):Contact Name(s): P -A
Mailing
Address, C/S/Z:
Cell Phone: _( ) Land Line: _( __.
Email: rg-LOCT
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• Manager: 04 2019 I
Contact Name(s):
Mailing Address, C/S/Z: OF�UEENSBURY
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Cell Phone: _( ) Land Line: _( `T-`- - -----
Email:
• Property Owner(s):
Business Name:
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _( )
Email:
Contact Person for Building & Code Compliance: A C,�t—
Cell Phone: ( ) Land Line:' (
Email:
Certificate of Occupancy Only Revised December 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: �;' , \
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Address (including suite, space, etc.): 1�� '� .,,,„
Type of business (i.e.: retail, car repair, etc.): Oc.p\--c--
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: (c___V-)‘NA.L__, ,,_CcpL17304Q1-
Applicant signature: 1 �
Date: ro ,1
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Certificate of Occupancy Only Revised December 2017
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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: 1bI � 2-CA
Business Name: aV231/4/sQ1As.)
Business Location (including suite, space, etc.):
Business Phone#:
1. Contact name: �.� V�
Main Phone:_( '� C _ <22-44 - Secondary Phone:_(
Coming from what town/village? CQ�S +`` �;
2. Contact name:
Main Phone:_( ) ; Secondary Phone:_(
Coming from what town/village?
TOWN OF QUEENSBURY FIRE MARSHAL'S OFFICE
P: 518-761-8206 F: 51 8-745-4437
FIREMARSHAL@QUEENSBURY.NET
FIRE MARSHAL MIKE PALMER DEPUTY FIRE MARSHAL GARY STILLMAN
Certificate of Occupancy Only Revised December 2017