CO-0288-2021 CERTIFICATE OF OCCUPANCY ONLY office use only
APPLICATION Permit#: CO ' 0ZSB• ZZI-A
Town ofQLxcnsbun• Permit Fee:$
742 Bay Road,Queensbury,NY 12804 Invoice#: �~
P:518-761-8206 or 518-761-8205 www.aueensbury.net
**This application is for occupancy only, with no work req ilding permit**
BUSINESS INFORMATION: a LC
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Name of business: APR 27 202,
Business Address (including suite, space, etc.): TO g�LDIN�UEENSeURY
12 c66 &�o°ems
Detailed explanation of business (attach a separate piece of paper, if necessary):
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***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:
Applicant signature•/�Izx Date: Z7 Z
Property Owner Zme:
Property Owner signatur Date: ZT Z
Certificate of Occupancy Only Revised December 2020
Town 4_1f Ctnrnsbun•
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): Vcct,J Lt4ruw`
Mailing Address, C/S/Z: '�2 $c.%y I ,e•�y ?(-` Q ,e��Syvr Y I2��14
Cell Phone: Lid-L-irr cell ! (Sl%) c(S5--037-C..
Email: .,a(el J Lc"C)roy" @ CaW1
• Business Owner(s):
Contact Name(s): t
Mailing Address, C/S/Z: Waw
Cell Phone: Land Line:
Email:
• Manager:
Contact Name(s): r�� �uKn
Mailing Address, C/S/Z: r� .� �K �d � � N V (2 Vat-(
ure Cell Phone: LgDd-L
Email: 14L5 b 7 Ue, S (P @
• PropertyOwner(s): G,r"I► 12 ,64 G�� Sow , �o be fU(CLLS e4C) �/Y-
Business Name: X(I R(I LLG
Contact Name(s): r
Mailing Address, C/S/Z: '5�'� G's ct bad
Cell Phone: Land Line:
Email:
Contact Person for Compliance in regards to this project: JO.� ('.ems rVVvt
Cell Pho5ower)
: -�irr�: (5-4) C{�j 5 - 6 3 Z�
-Email: L6vLd Eve e �r(•-vo - G®vv�
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Certificate of occupancy Only Revised December 2020
Totsm of(Lreensbun•
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: q /Z 7 ZdZ
Business Name: ���� �•�e. ��`�
Business Location (including suite,space,etc.): r(_ f
Business Phone#:
1. Business contact name:J�� Le
Main Phone: ; Secondary Phone: C511;�) Q� OZj7_& ��1�)71/Ce- /5-77
Coming from what town/village? &e\A S&-wL/
2. Business contact name: Le
PtA _ Z CS-1�5_ ?q 91 ( 5-77
Main Phone: ;Secondary Phone:
Coming from what town/village? Que-e0-Gl Wr-
TOWN OF QUEENSBURY FIRE MARSHAL'S OFFICE
P: 518-761-8206 F: 51 8-745-4437
FIREMARSHAL@QUEENSBURY.NET
FIRE MARSHAL MIKE PALMER DEPUTY FIRE MARSHAL GARY STILLMAN
Certificate of Occupancy Only Revised December 2020
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