application J CERTIFICATE OF OCCUPANCY ONLY Office Use Only
Permit#: CO J
APPLICATION
P, of O t ran�ur, Permit Fee:$
742 Bay Road,Queensbury,NY 12804 Invoice#: 3e
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):
( -( 1ailingAddress, C/S/Z: B f-rY\ C 6 t•-) 2_?O
Cell Phone: ) 2 lko Jb'4(T Land Line: ('( _).bO - q 00-
Email: 9\` —��4� ) 11 )(4-yL_' C' 0 'rr
• Business Owner(s):
Contact Name(s): l_2
b2-Mailing Address, C/S/Z:9 5-01
Cell Phone: _(z(j) 3 ( (Q O(p 0 Land Line: _(Si ) (Off- t c 00
Email: grnCOS
• Manager:
Contact Name(s): 6 t .^
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: _( )
Email:
• Property Owner(s):
If Business Name: t VeY1 tg-� 2
2l )-eA.i-e-cq CO,
Contact Name(s):
Mailing Address, C/S/Z: Ct S Ci .
Cell Phone:_. ) D-� I Land Line: _( )
Email: O(11J 1,-( u'.3 l.-A- c ic-S C7 "?,c rc\ck-e ...(.QJ()madin. • C °tm (
OIECEOWE0
-
OCT 20 2020 I
TOWN - SB_�
OF CUEENURY
BUILDING&CODES
Certificate of Occupancy Only Revised June 2017
,mot
limn o i �y»Tiers.
742 Bay Road,Queensbury,NY 12804
P:518-761-8206 or 518-761-8205 www.queensbury.net
BUSINESS INFORMATION:
Name of business: \ '-A.,C •
Address (including suite, space, etc.): +44-e_ 1(24 9 -L.Art
etesznsnorbA
,r2_,R01
Type of business (i.e.: retail, car repair, etc.): (1, 10�e k flokooc
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: ,t0/
Applicant signature:
Date: 'C) J
2-
Certificate of Occupancy Only Revised June 2017
le>+n ail CZ_t-i:pr
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-PERSONNEL
Date: 0 CT aQ cV
Business Name:
Business Location (including suite,space,etc.): ( \ 0\ A 1 TLU
Business Phone#:- lU 1. 5(91 �� l q 0 O.
1. Contact name .
Main Phone: SIB ) (p C)5econdary Phone:
Coming from what town/village? 84Ue. ScO \
2. Contact name: (-Z,. .CAr\l 42.
Main Phone:_e_a_R-3 a----- condary Phone:_(
Coming from what town/village? € J7A' K L)��1
I `
TOWN OF QUEENSBURY FIRE MARSHAL'S OFFICE
P: 518-761-8206 F:518-745-4437
FIREMARSHAL@QUEENSBURY.N ET
FIRE MARSHAL MIKE PALMER DEPUTY FIRE MARSHAL GARY STILLMAN
Certificate of Occupancy Only Revised June 2017