CO-0253-2021 CERTIFICATE OF OCCUPANCY ONLY office use oniv
APPLICATION Permit#: C-n
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Permit Fee:$ 11,
742 Bay Road,Queensbury,NY 12804 Invoice M:
P:518-761-8206 or 518-761-8205 www.oueensbury.net —
**This application is for occupancy only, with no work requiring a building permit'
BUSINESS INFORMATION.
Name of busine«: Gt��n 't �g /�„�r, t-�cvv,�r ul (dar ,UCI�,r/�cv�r �7'ii'd✓%Nv)
Business Address ;including suite, space, etc.):
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Detailed explanation of business attach a separate piece of paper, if necessary): :VIV/AVIA,-
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PR 20**Please provide an accurate layout of your space showing TZ.
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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: `�`/1' � Date: .0
Property Owner name: 6116,1 #% Aku'-/V
Property Owner signature: ��/! �' Date: l6 Lie-21
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certdicate of Occupancy Only Rev-sed December 2020
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742 Bay Road,Queensbury,NY 12804
P:518-761-8206 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.
Date.
Business Name: C7�N�1 S 5 LO V12 t�w_y (L,
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Business Location(including suite,space,etc.): (f ez ` j
Business Phone#:
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1. Business contact name:
Main Phone: ;Secondary Phone: S78 763 6033 I /�ell
from what town/village? �?fl7106,4 SDI,�,� S AI/
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@QUEENSF9URY.NE t
FIRE MARSHAL MIKE PALMER DEPUTY FIRE MARSHAL GARY STILLMAN
Certificate cf CccuDancy Only
Revised December 2D20
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742 Bay Road,Queensbury,YY 12804
P.518-761-6206 or 518-761-8205 www.aueensburv.net
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): ,/ /,
Mailing Address,C/5/Z: 10113 US 9 Q�VE6,t/SBuL
/Yt 11807
Cell Phone: land line: f S/e-7�3-8p3 3 �( ��d? �? 676 — u3—037Z
Email:
• Business Owner(s):
Contact Name(s):
Mailing Address,C/S/Z: `1 ly�t 3i. UN/�'y
Cell Phone: Land Line: 4o-7-1P-21*q (c) 60-7 VP-OYU'Cam)
Email: /Urc'g�A'�� C S/',Ly. /1/l, -rpm
• Manager: / /��A/`� 100L i7
Contact Name(s): kN/( //,A '^ �' GS"-O y
Mailing Address,C/S/Z: /O y3 u S y Q�-��sts C/'y
Cell Phone: Land Line: S7 7
Email:
• Property Owner(s):
Business Name:
Contact Name(s):
Mailing Address,C/S/Z: yi 614t^! Si-- 010l �r �'y �3`��
Cell Phone: Land Line: e1 (c
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Email:
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Contact Person for Compliance in regards to this project: A14Lx S c� ✓�
Cell Phone: Land Line: /�'15-/0 _ 7�i 3 _ �0 3 3
Email: l / `(,� �}
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cer i icate of Occupancy Only Revised December 2020