application CERTIFICATE OF-OCCUPANCY ONLY office use only
Permit#:- CA '_01 %&6 N Li _
APPLICATION
Permit.Fee:
TOWM of Qirecnsbury
$ lltl
742 Bay Road,Queensbury;NY 12804 Invoice#:. - .3�
P:518-761-8206 or 518-761-8205.- www.gueensburd.net
**This application is for-occupancy only; with no work requiring a building permit**
CONTACT INFORMATION:
• Applicant:
Name(s): � -��
Mailing Address C S Z:
Cell Phone: /�/: _) ti�f:-. 3 y. g 3. . Land Line: .
Email:
• Business Owner(0.-
Contact Name(s): �5��:-, a ke,,
Mailing Address, C/S/Z .
Cell Phone: Land_( ) Line:
_( ,
'
Email:
• Manager:. �A 2 9 � 21
-Contact Name(s): _
-Mailing Address, C/S/Z: TOWN OF QU
Cell Phone: _( . ) -Land Line: _(
Email:
Property Own&&..
Business-Name:._ /l��lo
Contact Name(s): _ 2tjn 5' -r-,�
Mailing Address; C/S/Z: 23. : �aLk bu_r►. a,Ss - ejZ . m� 14r� /-l.`/ H
Cell Phone: _( ) g9- • L y5 7 r� L e: _( ) '�;
Email:
Certificate of Occupancy.only Revised June 2017-:
7btsm d(Luccnsbury
742 Bay.Road;Queensbury,NY,12804
P:518-761-8206 or 518-761-8205 .www.queensbury.net
BUSINESS INFORMATION:
71
Name of business: :At-IIr-.; ,C_ .
Address (including suite, space, etc.-): ��y 1 2✓ ,� ,; .
'
Type of business (Le..: retail, car repair, etc.): LLk1A_it
Please provide an accurate layoutof 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 Queens.bury Fire Marshal's office. .Fire extinguishing systems
found in kitchens. and gas.stations:require semi-annual:inspec:tions. Any violations noted
during an inspection require immediate corrective action and a re-inspection.
Applicant name: J ;.,
Applicant
Date:
Certificate of Occupancy Only Revised June 2017_: ""
TONm oPC2Lrecnsbury
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 PERSON NEL:WHO.MAY BE CALLED TO.YO.UR
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 EIVIERGENCY SERVICE PERSONNEL MAY RESULT IN.
DAMAGE TO YOUR BUILDING BY POLICE AND/OR FIRE PERSONNEL.
Date: .
Business Name:
BusineSSL Location (including suite,space;etc.): v���/ 42 a=ke L : 6 '1�e_.4:
-Business Phone#:
1. Contact name: ���:!-n I�"'� "�l
Main Phone:_( I ) �/� //l;Z. ; Secondary Phone:_( �) �f/1 f' 3y19
Coming from whataown/viillage? S. /- S /��-1 I S
I Contact name: "`. �a V1
Main Phone::_(_0_i_' _): �,X- oWy Secondary Phone:_(
Coming from what town/village?. 5 Ue s
TOWN OF QUEENSBURY FIRE MARSHAL'S OFFICE
P: 5-18-761-8206 F: 518-745-4437
FIREMARSHAL@QUEENSBURY.NET...
-FIRE MARSHAL MIKE PALMER DEPUTY FIRE MARSHAL GARY.STILLM,4NI _W—e-1
Certificate of Occupancy Only Revised June 2017