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application :.`_ CERTIFICATE OF OCCUPANCY ONLY Office Use Only - _ 040.A, N.1/4- iz‘...-;-,n7:,..,,e, APPLICATION Permit II: CO Ig 3 s- 2010 Tann of Ctrcrn,bvl• Permit Fee:$ 100 742 Bay Road,Queensbury,NY 12804 Invoice tt• 5Drn P:S18-761-8206 or 518-761829E www.cureensbunr.net **This application is for Occupancy only,with no work requiring a building permit** CONTACT INFORMATION: • Applicant: Name(s): F (( Mailing Address, C/S/Z: l . O e 4i ;wt - fir' f` � — — — Cell Phone: (,�'�f 8 ) F2. �.- � - � - Land Line: ( ) Email: 1-con/4.90 ( ,c�,�" • Business Owner(s): Contact Name(s): roan ,/ - c4a p - Mailing Address, C/S/Z: `/Y7 gZ`atc / ate ? SiuYe if Aueenaary J oy Cell Phone:_( _2.47 _) s--IMee Land Line: _( ) . Email: pans • oca. Co • Manager: Contact Name(s): ( z-4o ) c/ eA Mailing Address, C/S/Z: 'zI � ,' /e- L ec,24 s 242Zb Cell Phone:,( ?(7_)2-7,1 (67 C Land Line: _( Email: a ow . Ill �* . D t - - 1 • Property Owner(s): O�� 0 9 202 Business Name: a ©s 1Ai,, - , �3 a. C- _ �- �Sbu�Y Contact Name(s): / o, -cowl°�N�c.C c°De Mailing Address, C/S/Z: _._--y-" Cell Phone:J -S i 7 ) 7 r(., Z.‘747 • Land Line: ( ) Email: - = Contact Person for Building & Code Compliance: FCC<c . C Cell Phone:- ( f ' ) -'� r z, Land Line: ( )` Email: `f — — e Revised September 2020 rtificate of Occupancy Only 111(evc. 7• i.)... Nniu of Q+crntbura• 742 Bay Roads Queensbury,NY 12804 P:518-761-8206 or 518-761-8205 www.aueensbu .ne 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: /°//3/ZA°Z Business Name: S'mo ie p _ - _ .. Business Location(including suite space,etc.): (75"`l State mu to -f - .fit ri`(m A ?bee n cA^ fr /2-474' r. Business Phone#: _ . .. 1. Business contact name: ti r Li B3ra G Main Phone:.. g_ _) Sif .rat ;Secondary Phone:j _ ) - Coming from what town/village? i �S OS / 7,1 . 2. Business contact name: / " CiGt Main Phone:_( ?/l ) 241 /'71 ;Secondary Phone:_( ) Coming from what town/village? S?.- GiU ' ✓ TOWN OF QUEENSBURY FIRE MARSHAL'S OFFICE P:518-761.8206 F:.518-745.4437 FIREMARSHAL@QU EENSBURY.NET FIRE MARSHAL MIKE PALMER DEPUTY FIRE MARSHAL GARY STILLMAN • Certificate of Occupancy Only Revised September 2020 town of Quccn buq; 742 Bay Road,Queensbury,NY 12804 P:518-761-8206 or 518-761-8205 www.queensburv.net BUSINESS INFORMATION: Name of business: cSA4oAZ. pv Address (including suite, space, etc.): ' apt& note. ? Su r' . • t7 hgh _ I2 0 . Detailed explanation of business (attach a separate piece of paper, if necessary): ***Please provide an accurate layout of your space shoving all walls, exits, stockrooms, rest rooms, counters: and Factures 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: }u44,, Chen Applicant signature: Date: 1°fb4/Z0 Property Owner name: fl'io n, o 1 laze( tic • Property Owner signature: , IM Date: dahL) Certificate of Occupancy Only Revised September 2020