application �= CERTIFICATE OF OCCUPANCY ONLY Office Use Only
APPLICATION Permit#: OD '' 01.65 -2-
Town orOgccnsburg� Permit Fee:$ (0t
742 Bay Road,Queensbury,NY 12804 Invoice#: 2-155'{`
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): 1\AR))11.11r> flIpOre foce- 1('
Mailing Address, C/S/Z: V1 rcozz( Lab P Ckd. i 1—nA
4 L
Line: S23 - 57S
Cell Phone: ( ) Land L e. ( �jlss ) 1
Email: La_ O-YV\S Ecb VA\)n11Iv, YIP(tIC(L • UL� r
• Business Owner(s):Contact Name(s): IIM,O/LTG.V\, 1 ► IpAvtJ vic --((
MailingAddress, C S Z: a-1 k i . iv(tf � . L;CP Ad I l '
Cell Phone: _( ) Land Line: ( 4K< ) S7? -'r
Email: La C i a.-ev A IA frA ( Ik_ YVI_ed f.
• Manager: `
Contact Name(s): LJrtk) •aI him
Mailing Address, C/S/Z: D-`'I 6AY-Ct hcj (' /t. tiI7,e AO C IO _Ny 001,0
Cell Phone: _( ) Land Line: _( ,�1� )
n (r p
Email: t� �t V�S � V 1 (I/\. `'�il.P�`L1�(,Ll ,
• Property Owner(s):
Business Name: a /O( ib -S- Yak
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _( )
Email:
Contact Person for Building & Code Compliance: ! — r vLi tr r m
Cell Phone: ( ) Land Line: ( I ) _. -_�
Email: JUL 30 2020
TOWN OF QUEENSBURY
Sill O NG. CODES
Certificate of Occupancy Only Revised December 2017
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Town of Q!ecnsbury
742 Bay Road,Queensbury,NY 12804
P:518-761-8206 or 518-761-8205 www.queensburv.net
BUSINESS INFORMATION:
rWVCCName of business: WOO
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Address (including suite, space, etc.): M l A1â i(t(
LQ P(OXIC l4Li(0
Type of business i.e.: retail, car repair, etc.): - P�� k"ii)
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: M(�Vk 5firviro,
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Applicant signature: ki1
Date: I 1ôJo
Certificate of Occupancy Only Revised December 2017
Town of Cjuccnsbuiy
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: 30[2n
Business Name:. n O Unr6 ( ( SSC
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Business Location (including suite,space,etc.): Jq RD C i SI Rc6r
Jeers bf.r1 Nt 050
Business Phone#: 5 is ' i LI - 696(00
1. Contact name: '\ C/0 U1(1 fl
Main Phone:_( l O2_ ) - I4 ; Secondary Phone:_(
Coming from what town/village? Ooep vc ( UA.y
2. Contact name: I Ie,1 1 t n ro-IN I P
Main Phone:_( 5i� ) 1`�[`► ` (jd(g ; Secondary Phone:_( I ) l.(D' 6 73 Z—
Coming from what town/village? V OGQ
TOWN OF QUEENSBURY FIRE MARSHAL'S OFFICE
P: 51 8-761-8206 F: 518-745-4437
FIREMARSHAL@QUEENSBURY.NET
FIRE MARSHAL MIKE PALMER DEPUTY FIRE MARSHAL GARY STILLMAN
Certificate of Occupancy Only Revised December 2017