CO-0127-2022 CERTIFICATE OF OCCUPANCY ONLY Office Use Only
QL Permit#: Co 2,b22_
APPLICATION
Tolm ofCh u
rccnsbry Permit Fee:$ 1
742 Bay Road,Queensbury,NY 12804 Invoice#:
P:518-761-8206 or 518-761-8205 www.gueensbury.net
"This application is for occupancy only, with no work re rK996049 a it"
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BUSINESS INFORMATION: !! 23 2022
Name of business: t126t tan 6-e�l
QUEENSBURY
Business Address (including suite, space, etc.): BUILDING &CODES
�s Q rRd , OwccoA dam, i2go�
Detailed explanation of business (attach a separate piece of paper, if necessary):
***Please provide an accurate layout of your space showing
all walls, exits, stockrooms, rest rooms, counters and factures
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: : C,044 xl(-d
Applicant signature: Date: 3 Z3
Property Owner name:
Property Owner signature: Date: 3 23 Z
Certificate of Occupancy Only Revised February 2022
Timm aff7gccnsbury
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): &«
Mailing Address, C/S/Z: 75- Q Jw 124 1 O, _s._t " f ly`/, /22`/
Cell Phone: ( SV ) sgs- usg5" Land Line: ( sus ) 3J!-,5V4
Email:
• Business Owners :
Contact Name(s): l(A Z4.d
Mailing Address, C/S/Z: 2/[< Pe6l + PO /V` IZBIL
Cell Phone: _( ) Land Line: _( )
Email: jjrp4LAZATFL- o Gam,;; , 6an�
• Manager: �Cc An
Contact Name(s): /y►i
Mailing Address, C/S/Z: �/� [� ,rv}r+rhr�,Sfi,r,�r, /�6 �ax 71 A; /��'°/2?3LL
Cell Phone: _( !r ) 79f �f/&S� Land Line: _( )
Email:
• Property Owner(s):
Business Name:
Contact Name(s): I�li�1 �rl
Mailing Address, C/S/Z: 7Aff G9c-5L-t „-r. S rt, 7�) RR,4 SY70, t6& /
Cell Phone:_( 5lf� ) gS,& - 03HS Land Line: _( )
Email:
Contact Person for Compliance in regards to this project: ALL-d N �1
Cell Phone: ( s/1Z )_9?$'- Land Line:
Email: AA NArNN-5- 12 014Ag!J. Lom
Certificate of Occupancy Only Revised February 2022
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Town of CLuccnsbury
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: ,�//ar-c(ni ZoZZ
Business Name:
Business Location (including suite,space,etc.): '75- S",
Business Phone#: 6 l�jl
1. Business contact name: L*i c 10146/c4
Main Phone:_() 7�� ;Secondary Phone:_( )
Coming from what town/village? A42& /n 6r�
2. Business contact name:
Main Phone:_(�_) 8 ' d3 ;Secondary Phone:_( )
Coming from what town/village? sS� S�a-r5
TOWN OF QUEENSBURY FIRE MARSHAL'S OFFICE
P: 51 8-761-8206 F: 518-745-4437
FIREMARSHAL@QUEENSBURY.NET
FIRE MARSHAL MIKE PALMER DEPUTY FIRE MARSHAL TYSON CONVERSE
Certificate of Occupancy Only Revised February 2022