CO-0335-2021 p � CE0dIE
MAY 0 9 2021
C RTj 1�&ff GRAN ONLY. Office use only
L CODES Permit#: CD J'z'J'J`J
APPLICATION �1
*arwm6my
Permit Fee:$
742 Bay Road,Queensbury,NY 12804 Invoice#:
P:516-761.8206 or 518-761-8205 www.aueensbury.net
"This application is for occupancy only, with no work,requiring a building permit"
BUSINESS INFORMATION:
' e
Name of business: G�f A s n cr1 mi l�.�o N- (�� In( . NSA
Business Address (including suite, space,etc.): L- t hV��� 11' .- .� cdo
I
Detailed explanation of business (attach a separate piece of paper, if necessary):
UV
Q U
e Please provide an accurate layout of your space showing
all wall, eats, stockroo s, MA t00MS,, CoallsterS and fIIX>toreS
on a separate sheet of pap e- rO
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. Anyviolations noted
during.an inspection require immediate corrective action and a re-inspection.
Applicant name:
Applicant signature: }t` ,� Date: La
o
Property Owner name:
Property Owner-signature: Date: J
Certificate of Occupancy Only R-vised December 2020
Tom and
742 Bay Road,queensbury,NY 12804
P:518-761-8206 or 518-761-8205 MM.gueensbumnet
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
Applicant:
Name(s): .)g-v5
Mailing Address,C/S/Z:- A, k n' k \'.-O
Cell Phone; lan'� Line:
Email: ( jt-A-7 f, ,-y-
-Business Owner(s):
Contact Name(s): A:C1
Mailing Address,C/S/Z:
Cell Phone:JLL --)�l 1 (C\' r Land Line: J5 J 6`
Email:4Ji i,o,; 0,'k f U--i
Cv Manager:
Contact Name(s):
Mailing Address,C/S/Z:
Cell Phone:_(_) Land Line:
Email:
Property wner(s):
Business Name:
Contact Name(s): A
Mailing Address,C/S/Z: -,Pi V?i 1 rJ4
Cell Ph Land Line:
Email: 6, 0L.` i:j
Contact Person for Compliance In regards to this project: .,!)Aiyw rl'n 01 x
Cell Phone:I Land Line: (_)
Email:
Certificate of Occupancy Only Revised December 2020
QL
T0W dQV0Mkrry
742 Bay Road,Queensbury,NY 12804
P:516-761.8206 or S18.761-8205 www.aueensburv.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.
p �.l
Date: _�•.;i
Business Name , :�`� '� (;.-� k 'I - I �, ��°it r `.>=f i``,• i
Business Location(Including suite,space,etc.):
cvcs
Business Phone#:
4
1.. Business contact name:
Main Phone:_6(y% ) 1 •Secondary Phone:
Coming from what town/vlllage7:
2. Business contact name: A\,, 1i t 1r 1 ci C
Maln Phone:_(_._, 1 'r� R 09q Secondary Phone:_(�1
Coming from what town/village?
TOWN OF QUEENSBURY FIRE MARSHAL'S OFFICE
P:518-761-8206 F:518-745.4437
NREMARSHALOQUEENSBURY.NEI•
FIRE MARSHAL MIKE PALMER DEPUTY FIRE MARSHAL GARY STILLMAN
Certlflcate of Occupancy only Revised December 2020