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CO-0748-2022
r CERTIFICATE OF OCCUPANCY ONLY office Use only E A Permit#: CO— ©`�A: 7_07 Z Town of C_rctinsbun Fmyx�4� 9 V � Permit Fee:$ 742 Bay Road,Queensbury,NY 12804 Invoice#: P:518-761-8206 or 518-761-8205 wwwlb=,2 2022 ENSBURY ES "This application is for occ h rk requiring a building permit** BUSINESS INFORMATION: -t an � S ^�- 4 Name of business: VtkS I 11 � Business Address (includin, uite, space, etc.): WLe�� c 4i�,Detailed explanation of business (attach a separat piece of paper, if necessary): ***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: l Applicant signature: _ _ Date: Property Owner name: Property Owner signature: ~---Date: Certificate of Occupancy Only Revised September 2022 Town of Qg!ccnsbuq 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): iy 'k c- Mailing Address, C/S/Z: Cell Phone: (!ln ) 3 (nt In Land Line: Email: • Business Owner(s): Contact Name(s): Mailing Address, C/S/Z: Cell Phone: _( ) Land Line: _( ) Email: • Manager: Contact Name(s): Mailing Address, C/S/Z: Cell Phone: _( ) Land Line: _( ) Email: • Property Owner(s): Business Name: G Q Contact Name(s): Mailing Address, C/S/Z: '29 �'7--'Yx a S,1 'SC-: Cell Phone: _( ) Land Line: _(5► 8 ) `�-�2_ `�- Email: Contact Person for Compliance in regards to this project: l C11J1V11(u Cell Phone: Land Line: Email: Certificate of Occupancy Only Revised September 2022 I -309.11-2-36 CO-0748-2022 Assemblyman Matt Simpson 4 Western Ave S, Ste 3 N Certificate of Occupancy a „b,L--� cd ,I „OT cv 0 o 00 PA 3611 „ ovU i .o - �Wxllvc, S. 5300� ONIa inanSN3no-10 NMO ZZOZ 8 Z 339 e 3G" F_ Svre � IiI-e, I o,5 l� „L,SZ J � • O a 5