CO-0355-2022 2022-06-07 10:19 CDT 5184098130
+15184098130 PAGE 4i"
\\�\\. CERTIFICATE OF OCCUPANCY ONLY Of€iceUse On1y
Permit#: C-0 ' a%;5455 " 20 2 -
. APPLICATION
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� ggggggqq Permit Fee:
EE `$ Invblee M.
Bay Road,QueensburV,NY 12804
P:518-761-$206 or 538-761-8205
NIA OF :ENSBURY
rs
"This application is for occ ��R t � h`� kk requiring a building permit"
BUSII N55S.INFORMATION:
Name of business: rA.9 mea s I V s= an4cc M e,ze611 Agc-dc
Business Address (including suite, space, etc.): ' sy s f-t'rf Ro rC 1-3 5-1 ITS Af// erelsf-C, 6,
Detailed explanation of.business (attach a separate piece of paper, if necessary):
p .xXJ�4cJPxi.1G� r[d��'��:a � 7�'vbS fi� .;iL�"�G�S �ar1 �-!S97a1i.� ;'dGrFC.dC,,"�5
PIGM
provide an accurate spaft Showift
-- g ,, stockrooms, rest roomS., Coonten and
on a separate s papa***
IMPORANT:The business owner is responsible for[seeping 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: /A v C-M .4,'i
Applicant signature: j[s ,. Date: 6 4z Z
Property Owner name:
t
Date:
Property Owner signature: �' •, ;�>;: `:`,`
�. ..�.:;
certificate of occupancy Oniy Revised Fpbruary 2022
2022-06-07 10:19 CDT 518409'0130 +15184098130 PAGE 6i,
742 Bay Road,Queensbury,NY 22804
P:518-761-8206 0 518-761.8206
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
Applicant.
Name(s): tf Jc r4'q%� i' "Mc rzo ot
Mailing Address, C/S/Z: ay G a n
Cell Phone; `s`!8 2 y - s a m Es Land Line: ) 0-11 d 3
Email: Ill ' k e ����' 1 c;
Business Ownelr(sl:
Contact Name(s): ; C' A 5 A AA�
Mailing Address, C/S/Z:
Cell Phone:_{ ) _ Land Line: _{, )
Email:
a Mana&er:
Contact Narne(s); 34 M A s A Ov V
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line: _( )
Email.:
Property Owner(s.)a
Business Name• "Zim
Contact Name(s): 44 0 a i" g, 8 r-s e
Mailing Address, C/5/Z:
Cell Phone:_( T('6 ) '?q 'Z 7�6 '7 _ _ Land Line: _ �� } � - 00 Z�
Email: &'�Amo �Qe„�CSG 'L` `t?)o+�•�c>> LF'"'� -
Contact Person for Compliance in regards to this project:
Cell Phone:S_-__-_) Land Line:
Email:
Certificate of occupancy Only RevI'sed February 2022
2022-06-07 10:19 CDT 5184098130 +15184098130 PAGE 7/7
742 Bay Road,Queensbury,MY 22804
l9:SIB-761-9206 or 518461-8205 N � <i",sderasb <aam
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: �.►v,�� '� �o �, �
Business Name; w s �a ,.. .�,� c.�c M a z a AC-;
Business Location (induding sure,space,etc.): C) S'`� -r i•" 'T'C J a Fpjj f
Business Phone#: 5"t - q 09 - ''0 3 3
1. Business contact name: I-J qr# C L
Main Phone-_( It ) iZ � � �� `� � ;Secondary Phone:
Coming from what town/village? t e j S_-p�R t t a
2. Business contact name: —
Main Phone:_(__ _ ) :Secondary Phone:
Coming from what town/village?
TOWN OF QUEENSBURY FIRE MARSHAL'S OFFICE
P:518-75 t-8206 F:518-745-4437
FIRE MARSHAL MIKE PALMER DEPUTY FIRE MARSHAL TYSON CONVERSE
Certificate of Occupancy Only Revised February 2022
2622-06-07 10:19 CDT 5184098130 +15184098130 PAGE 5/'
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f
1.
EG
JUN 0 7 2022
NS13URY
TOWN OF DES
BUILDING
296-13-1-18 CO-0355-2022
Farmers Insurance - Metzger Agency
959 State Rte 9, Ste N
Certificate of occupancy
41
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