application CERTIFICATE OF OCCUPANCY ONLY Office Use only
44,411114,
Wer0 '` APPLICATION
Permit#: ,c" 052 3 •- Z0
Permit Fee:$
Town of gyecnsbuzy
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742 Bay Road,Queensbury,NY 12804 Invoice#:
P:518-761-8206 or 518-761-8205 www.queensburv.net
**This application is for occupancy only, with no work requiring a building permit**
CONTACT INFORMATION:
• Applicant:
Name(s): �i Lgyv) .\glit
Mailing Address, C/S/Z: ? Sc\1_6 , S-k �5 1 rn P c/).3
Cell Phone: ( qo I ) D 1-=1-1 en- Land Line: (
Email:
• Business Owner(s):
Contact Name(s): c i I Ivt - Q S lA Z
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line:
Email: _(
j - J "�
• Manager: 1 � P 0 3 20
Contact Name(s): hA3 �11sl"11)(,4f ti� ►Q►Jvr.l rfi "" __
Mailing Address, C/S/Z: I Rc er P t P5 � ;��cbLJ€iy
Cell Phone. Land Line: _(
Email: 6- S riccc:k Vg ycrk ,Ccmry
• Property Owner(s):
Business Name: :5:zfd- ck Q n Nk-a4CU 1
Contact Name(s): FctA
Mailing Address, C/S/Z: a IC 3q C- t,U Vitm)t►Uy 0T31
Cell Phone: ( 57F ) 57� - aim Land and Line: _( 57Z )
Email: of I I e- 1(5a1 t (oY
Contact Person for Building & Code Compliance: C11t�3 WeiShi w t
Cell Phone: ( F1E ) 5'b1- Lion Land Line: ( )
Email: i 501,,(Akneyakoticom
Certificate of Occupancy Only Revised December 2017
"limn of Cjirecn'sliud}
742 Bay Road,Queensbury,NY 12804
P:518-761-8206 or 518-761-8205 www.gueensbury.net
BUSINESS INFORMATION:
Name of business: _ N -' K -- ` T,umto
Address (including suite, space, etc.): I LI " I Rcxk_C
A $844v Ny I i)(z i
Type of business (i.e.: retail, car repair, etc.): Reir 115cmtie11.r 54b
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: LctrviPr
Applicant signature:
Date: 9\Qo1b
Certificate of Occupancy Only Revised December 2017
cs
Town of Cieensbue}'
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: Ne lo 1 -if\A ()
Business Location (including suite,space,etc.): T ' 1 OU—
ue-�.u�s a cit.5
Business Phone#: 1101'3 3_- -(1 h
1. Contact name: C\r ri5 W(1.41 (I�n
Main Phone:_( )
5 ua 3 ;Secondary Phone: (
Coming from what town/village? i &SM ! 1051 I)\I
2. Contact name: ILJ ( ram kx-)45�lOikc �
Main Phone:_( �1 b ) 1 (5 0093 ;Secondary Phone: (
Coming from what town/village? 1-1-1A6 ,<AA rrki6) t\•)\
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