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0,040,,1 CERTIFICATE OF OCCUPANCY ONLY Office Use Only Permit#: " 2��1 APPLICATION ,,,;. c++,<�:,. 't Permit Fee:$ 742 Bay Road,Queensbury,NY 12804 Invoice#: 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): i-1-7-15 ( 1!1;2D Mailing Address, C/S/Z: 33 ej OLJA.Scb,j 64-43 .. lono.31 Cell Phone: ( 516 ) 30'7- 6c)17 Land Line: ( ) 7/7- 6,417 Email: ckfck9c,n CI1r c@ Y\ • Business Owner(s): Contact Name(s): „SA f►P1 -- _ Mailing Address, C/S/Z: ;-.A r Cell Phone: _( ) Land Line: _(_'' ) Email: l, � �4 � ! MAR O b 2019 � • Manager: q =�..Jq }a pRY _ 1�.74 JIV !c r ..4`di iJC.tR Contact Name(s): - �� B ` Mailing Address, C/S/Z: Cell Phone: _( ) Land Line: _( ) Email: • Property Owner(s): Business Name: ` vH a.� i S`t J-X-hwez,c4 Contact Name(s): Mailing Address, C/S/Z: Cell Phone:_( ) Land Line: _( Email: Contact Person for Building & Code Compliance: 4@?\, ont- Cell Phone: ( ) Land Line: ( Email: Certificate of Occupancy Only Revised December 2017 . 1,«." ?: 742 Bay Road,Queensbury,NY 12804 P:518-761-8206 or 518-761-8205 www.queensbury.net BUSINESS INFORMATION: Name of business: B .sT i4Dy U ai l- O,,1 Si—OWL Address (including suite, space, etc.): CIT-1 )cilAT (j' aE ).ts: x 1 L/ a4&04 Type of business (i.e.: retail, car repair, etc.): Pliftt...- \JaThp,is 4 5i N\3 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: p}} £- fre2rliti) Applicant signature: L cl _ . z3 � 1 ' j Date: f Certificate of Occupancy Only Revised December 2017 butt 110,11'1 742 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: (142Cf1 671' ©) Business Name: B4sr BcAc,/ bIU I pesTren3 ` 0 Business Location (including suite, space, etc.): (379 )2007.7 QJ3)/ 1\1.1 )).Po Business Phone#: 51 ? 7q 3 - ©3/6 1. Contact name: 4rQ� �' ea�fl Main Phone:_( 5IY ) - t7 ; Secondary Phone:_( 5/8 ) 7y7-. 601f 7 Coming from what town/village? (A9S11 FAILS S 1I_\/ 0 831 2. Contact name: u i,.jj fiMz. 12.11,ZP Main Phone:_( 1/451g ) 30-7- 3 ; Secondary Phone:_( _) 7o, 601(7 Coming from what town/village? ). S I`�,\j, )I2 f 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