application CERTIFICATE OF OCCUPANCY ONLY Office Use Onlynn ram/
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n Permit#: l�7— d c� 6 3 -��
APPLICATION
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t l� �i 1 i Fee:$ Q dr�
Town of enstiva►
742 Bay Road,Queensbury,NY 12804 D sir�0 c #: / ��
P:518-761-8206 or 518-761-8205 www.queensbu t SEP 18 2020
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TOWN OF QUEENSBURY
**This application is for occupancy ordOillitagi W requ'ring a building permit**
CONTACT INFORMATION:
• Applicant: ��� 6 6 Name(s): (-
Mailing Address, C/S/Z: 1 `L I'1 16t;t) ,ti (AL, , t,eo,=;S/ P/V / -V 7
Cell Phone: ( 5-s ) 51?4--6'1 4' Land Line: ( )
Email: f;l-1 Fro'11 CAVA WA-L-w1, , e Gv t ot=t L d-ovt-v
• Business Owner(s): b S � t 44 c,�_.
• Spq,ie-A-
Contact Name(s): �� 4btr7"
JMailing Address, C/S/Z: t
Cell Phone: _( ) Land Line: _( )
Email:
• Manager:
Contact s <44 n LP L )fi
Mailing Address, C/S/Z: ! ��t' _
Cell Phone:_( ) 7h v— 19, 13. Land Line: _( )
Email:
• Property Owner(s):
Business Name: /Jb 6,Acc v qu"ti . C 7rik14,
Contact Name(s): La LINpi
Mailing Address, C/S/Z: 717 ut-P-P — 6/1164,., i'. /,c)—y 9 ( , 'x 40
Cell Phone:_( ) Land Line: _( )
Email:
Contact Person for Building& Code Compliance: -14)IP° 3
Cell Phone: ('S/� ) 5 U&-4 14 Land Line: ( )
Email: /S1J'ru.w4, CDA • LA-
Certificate of Occupancy Only Revised September 2020
Town of Owen-
tcnsbury
742 Bay Road,Queensbury,NY 12804
P:518-761-8206 or 518-761-8205 www.queensbury.net
BUSINESS INFORMATION:
1
Name of business: —/W sl" i _u,ti3
Address (including suite, space, etc.): 7/I 7 ttPf '- 0i: 0 51- 6-is / 4
CNI StAt . 4' R 6tkiac..ENJL-tk//u/pioK
Detailed explanation of business (attach a separate piece of paper, if necessary):
VL,t4 e le - l ,5eP-✓1 LF
***Please provide an accurate layout of your space 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: O 6^
Applicant signature: Date: eihs-- 0
PropertyOwnerd l 1 /Jf'11lf4it 4 471 (1, s- )74c
name:
Property Owner signature: r j L Date: Z`6 Zd
Certificate of Occupancy Only Revised September 2020
A y j
Town oP'C ctnsbury
742 Bay Road,Queensbury,NY 12804
P:518-761-8206 or 518-761-8205 www.queensburv.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 PERSONN .
Date:
Business Name: l7 ( -i1.1 tKI-CiAl
Business Location(including suite,space, tc.): 717 G`C �! ‘2 ,,v--
1 �L‹ l�L /
CuprzTh-40019bei eettifv) o .,44-1-4 ,,B e.Q__.t„Lik- Lifi-e,p)
Business Phone#: '57e ✓ 7 --5/
1. Business contact name: ‘---k(Wcec-66.3pr
Main Phone:_(6-7 i ) 9 3-1I'S?) ;Secondary Phone:_( 9 & s --4aq
r
Coming from what town/village? lbwsgodis
2. Business contact name: frAifirilor ` —0t, D(24Y'X
Main Phone:_(c---C ) 741.) Secondary Phone:_( )
Coming from what town/village? 624 k P Y- 6(41 fir.
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 September 2020