CO-0676-2021 CERTIFICATE OF OCCUPANCY ONLY office use only
APPLICATION Permit#: 0) Olo - 20
Permit Fee:$
7d7H7t�'C�[Crp1
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 requiring a building permit**
BUSINESS INFORMATION:. tE
Nameofbusiness: C444i �� Ci✓tIYAM- P jSfw1C%S ALLBusiness Address (including suite,space, etc.):q BURY
UNSr3 /! NY lL�� O®`S
Detailed explanation of business (attach a separate piece of paper, if necessary):
p9ovipt- (NNIMNty 1�_VM J5 4VA) (?*PAW L.S i LAjoo0 5�v�iOH1mN��t c.cr�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: "
Applicant signature• 1. r_� Date:
Lou
Property Owner name: �.
Property Owner signature: l� e: b
Certificate of Occupancy Only Revised December 2020
TIMM oFi�ueeksbu�
742 Bay Road,Queensbury,NY 12804
P:518-761-8206 or 518-761-8205 www.gueensburV.net
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): K*-NNST-L-1 BfRowri
Mailing Address, C/S/Z: t-16' 60-OAD S-MceeT
Cell Phone: Land Line:
Email: V/N@ CPSct��W�NtiY, Cowes
• Business Owner(s):
Contact Name(s): t36L3 FAv&+-41VPgJ t Z$D 1
Mailing Address, C/S/Z: (15- .13it-oA0 6VL�( GAS H
Cell Phone: Land Line: 511-.?3t-- 431& 1 1 S 30'7 -7-370
Email:
• Manner:
Contact Name(s): Kth*J'rhA U4vj-,-3
Mailing Address, C/S/Z: 1-?S R ez_ --D S�ctZ•� �^-'� '�'g t �Y
Cell Phone: Land Line: u 1 b- 3Le(o- 612t l
Email: tL�� G'�t-�vv�s�l �n1�-►�F'. �c�w`
• Property Owner(s):
Business Name: Lour FP e-A ONI.
Contact Name(s):
Mailing Address, C/S/Z: #22(.v 4cu`I1- .S'O P hi A t
Cell Phone: Land Line: $7�r— 3-7 8- q�3z
Email: �F-��t,�vp\sN (9.v►ti+An� - Corv�
Contact Person for Compliance in regards to this project: Kilaw v"',r%l 812owyJ
Cell Phone: Land Line: - 3U&_ �Z J l r -V8--30-7 —73`70
Email:
KerN-e 0-rA1fP5&A44 MAf,-Y- C&M
Certificate of Occupancy Only Revised December 2020
Town of tiWnsbnq
742 Bay Road,Queensbury,NY 12804
P:518&761-8206 or 518-761-8205 www.aueensbury.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: �h ,
Business Name: 641AM!' 6q/1yt1V;Ey '*104q C 95 111/6
Business Location(including suite,space,etc.): VY5,
Business Phone#: 3� a- 30 7— 73 70
1. Business contact name: or"N4114
Main Phone: ;Secondary Phone:
Coming from what town/village? Ou JeW4 6WIPAY P NY
2. Business contact name: gc(,3 f,4v4--1-1/VyW
Main Phone: ;Secondary Phone: 33�j_'
Coming from what town/village? C'lJ���i?7(/1 /' f
TOWN OF QUEENSBURY FIRE MARSHAL'S OFFICE
P:518-761-6206 F:5 1 8 745-4437
FIREMARSHAL@QUEENSBURY.NET
FIRE MARSHAL MIKE PALMER DEPUTY FIRE MARSHAL GARY STILLMAN
Certificate of Occupancy Only Revised December 2020
FIRE MARSHAL'S OFFICE
Tozvn of Queensbury
742 Bay.Road, Queensbury, NY 12804
"Home of Natural Beauty ... A Good Place to Live "
PLAN REVIEW
Champ's Chimney Sweep
845 Route 9
CO-0676-2021
9/10/2021
The following comments are based on review of drawings:
• Verify fire extinguisher location and inspection
• Verify operation of exit/Emergency lighting., including basement
Lock/ latches shall comply with Chapter 10 of 2015 IBC.
• Knox Box for FD entry required, Model 1200
• CO detection is required if a source is present
Michael J Palmer
Fire Marshal
742 Bay Road
Queensbury NY 12804
firemarshal@queensbury.net
Fire Marshal 's Office Phone: 518-761-8206 Fax: 518-745-4437
firemarshal@queensburj.net z WW.queensbuMmet-
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302.5-190 CO-0676-2021
Champs Chimney Services LLC TOWN OF QUt� NSFIJRIY
845 State Rte 9 BU��D��O`� `O "
Certificate of Occupancy Only
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