application - CERTIFICATE OF OCCUPANCY ONLY Office use Only
APPLICATION Permit#: CO -8 -27) - Z102-1
Permit Fee:$ 110 Jam,
742 Bay Road,Queensbury,NY 12804
Invoice#:
P:518-761-8206 or 518-761-8205 www.gueensbury.net
**This application is for occupancy only, with no work requiring a building permit**
BUSINESS INFORMATION:
Name of business: (}'�-v
Business Address (including suite, space, etc.): `-I�
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Detailed explanation of business (attach a separate piece of paper, if necessary):
Can QJ1J A'L/
***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: EJciy
Date: 1 i0 i,9o�
Applicant signature: / �iG/ ���G�".
Property Owner name:
Property Owner signature: i D
p Y gate:
Certificate of occupancy Only Revised December 2020
Co - i 53- 2z21
linen u1[�ucriia,un
742 Bay Road,Queensbury, NY 12804
P:518-761-8206 or 518-761-8205 www.gueensbury.net
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s):
Mailing Address, C/S/Z: -7\ '\1Q1 �1< d5c�,i U �aGy
Cell Phone: -
E m a i I:S e,oteC\`au\@\vA
• Business Owner(s):
Contact Name(s):
Mailing Address, C/S/Z: GS
Cell Phone: Land Line: 1 CG' °`
Email:
�9AR 2 5 Z�'%1
• Manager: TOWN pE aUL-ENSBURY
Contact Name(s): alllLbINIG v.CODES
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
Property Owner(s):
Business Name:
Contact Name(s):
Mailing Address, C/S/Z: �(G I Joc,,j GveGn 3'X'Rf fuly
Cell Phone: '3 09-2S
Contact Person for Compliance in regards to this project: Scc�z LCi1C�lc/
Cell Phone: -I =ng I a gb0l -
Email: c,��
Certificate of Occupancy Only Revised December 2020
!i a u of c`ercclI,bI)n'
742 Bay Road,Queensbury,NY 12804
P:518-761-8206 or 518-761-8205 www.gueensbury.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:
Business Location (including suite,space,etc.):
Business Phone#: S��_ LI al
1. Business contact name:
Main Phone: ;Secondary Phone: 'S'N �C a��H
CA
`7z lM;- ul 001
Coming from what town/village? Lam LvZPr �-
2. Business contact name:
Main Phone: ;Secondary Phone:
Coming from what town/village?
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 2020