application CERTIFICATE OF OCCUPANCY ONLY Office Use Only
t Permit#: CO—OW2.1 2020
APPLICATION
Permit Fee:$ )00
TOW]of Ctcenibilry
Invoice#: tcl 0
742 Bay Road,Queensbury,NY 12804
P:518-761-8206 or 518-761-8205 www.queensbury.net
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**This application is for occupancy only,with no work requiring a building permit**
CONTACT INFORMATION:
• Applicant:
Name(s): 0( c1-16 e- r
Mailing Address, C/S/Z: PLore / I.tr', t- 4o 7 S`Arcti=I—34 r,,.� s �� ;����
Cell Phone: ( 2 ) ? Land Line: _( )
Email: n\GS.3Lin 6Sr<��� �-f ro n
• Business Owner(s):
Contact Name(s): L-
Mailing Address, C/S/Z: pia, 1r,,ei4 Pi_ it-0 7 5�►r,.J , r"y (2cF46
Cell Phone:_( 5 1) 3t s7:�0 Land Line: _( )
Email: J .,ti trvi c_5 43 Ca 4 49 1
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• Manager:
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I
Contact Name(s): ��Lon 'e, NOV 2 0 2020 `�
J
Mailing Address, C/S/Z: _ _ _..a--:�.-a
Cell Phone:_( ) Land Line: _( T- Y\i�l i5l= ii. vl•;: ..F. :.'
Email:
• Property Owner(s):
Business.Name: Li k-e &r Lae— iLie".4/1
Contact Name(s): Go re-y S e\4,11 S '
Mailing Address, C/S/Z: 4106 eD.4-e-(' 54-- ie' 'v L(/as-77
Cell Phone:_(Ci4 ) 7i j 8-1/3-41 Land Line: _( q1 ,i ) 2 3 65-o
Email: r) -41 -5Acr 4-5 M ct.let-,e-rele_d -/ .
Contact Person for Building & Code Compliance: 411 —
Cell Phone: ( ) Land Line: ( )
Email:
Certificate of Occupancy Only Revised December 2017
Town of{etccnsbuay
742 Bay Road,Queensbury,NY 12804
P:518-761-8206 or 518-761-8205 www.queensbury.net
BUSINESS INFORMATION:
Name of business: l✓' Jle.(L,0-5.)2'' - I1 `' v r "-7
Address (including suite, space, etc.): 14 a 3 M- -e- '+Q- ci
Lp k ()tic,4 I L_Ake— 6e,„c 1e. ioq t o 8 t
Type of business (i.e.: retail, car repair, etc.):
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: �..1 7.4M6_ .01 C 97,,t7
Applicant signature:
Date: // /q —02002-6
Certificate of Occupancy Only Revised December 2017
Th yn of CZecns[iun
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:
o f L �-Vfl �'i o e c s-1.9`✓^� ._- ---i c
Business Name: h�
Business Location (including suite,space,etc.):
Business Phone#: -§ v .be- ��Je rnz
•
1. Contact name: n rnC
Main Phone:_( -31 ) 3 63 "73 vL ;Secondary Phone:_ )
Coming from what town/village? S�1 f f t /v
2. Contact name: C-s1��44L Ji GJ j'i A
Main Phone:_(- i ) ;'� 7 a `/t ;Secondary Phone:
Coming from what town/village? ,,J f 4.:k.e s._
TOWN OF QUEENSBURY FIRE MARSHAL'S OFFICE
P: 5 1 8 7 6 1-8206 F:518-745-4437
F(REMARSHAL@QUEENSE$URY.Nc.f
FIRE MARSHAL MIKE PALMER DEPUTY FIRE MARSHAL GARY STILLMAN
Certificate of Occupancy Only Revised December 2017