CO-0278-2023 x CERTIFICATE OF OCCUPANCY ONLY office use only
Permit#: CO -6.9-16'-off,
APPLICATION
- Permit Fee:$ f��00
Town of Qyccnsbun
742 Bay Road,Queensbury,NY 12804 Ind
P:518-761-8206 or 518-761-8205 www.gueensbury.net
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"This application is for occupancy only, with no work re uirin b�uijding permit"
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BUSINESS INFORMATION: 4 2
Name of business: lock El l- I ? .2 � b n _ ,
Business Address (including suite, space, etc.): I LI
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 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: Date:
Property Owner name: la ifrlC� �r^
Property Owner signature: Date: S LP
Certificate of Occupancy Only Revised September 2022
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Town of Quccn
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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/ : C ? h OU C, 61 e_ 2 4&-e- 6ea/1 `& 01
Cell Phone: ( S/9 ) 1,! - 67 1 , Land Line: ( 9;/7
Email: 645 !N- C !P 14071
• Business Owner(s):
Contact Name(s): G
Mailing Address, C/S/Z: 16 L)VZ., ` Z d
Cell Phone:_( 1V '16�1 b Land Line: _(
Email: AL
• Manager:
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _( )
Email:
• Property Owner(s):
Business Name:
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line: _( )
Email:
Contact Person for Compliance in regards to this project: ,Vt
Cell Phone: Land Line: ( )
Email:
Certificate of Occupancy Only Revised September 2022
Town of Qucensbun,
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: 15 2 5/2 5
Business Name: ,d
Business Location (including suite,space,etc.): r�l y� ����� / c ��� `� J�� L
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Business Phone#: .5 `A — ea ? OYN
1. Business contact name: VX
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Main Phone:_( ) G O ;Secondary Phone:_( )
Contact is coming from what town/village? / Q
2. Business contact name: 4e P//
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Main Phone:_( Secondary Phone:02, _( )
Contact is coming frrom what town/village?
TOWN OF QUEENSBURY FIRE MARSHAL'S OFFICE
P: 518-761-8206 F: 518-745-4437
FIREMARSHAL@QUEENSBURY.NET
FIRE MARSHAL MIKE PALMER DEPUTY FIRE MARSHAL TYSON CONVERSE
Certificate of Occupancy Only Revised September 2022
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REVISION
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3,1Z Counterparts and Electronic Transmission:BectronicSignatur This Agreement maybe executed in
any number:of-bountdrpar%each of-which shall be deemed.to be An.original and'all of which together shall be
dO'emed' , to:be one l th.6 same Instrument. Copies of this Agreement with signatures that have been
transmitted b I y email &::by,f&dm.i1e.shall constitute and be deemed original copies of this Agreement for all
purposes;provided that the copies are fully executed;dated and,identical In form to tho.origirial hard copy
Version of this:Agreement. in addition, this Agreement .may be signed electronically by the Parties and
electeoniadgnaturasappeoiring on.thisAgre.ament shall b6deemed.to bethestimeashandWritteri signattipesfor
Mppurposescif thevalidity,enforceability and admissibility of thisAgreement.
IN WITNESS WHEREOF,the Parties have executed thisAgreement asof theEffective Data
FRANCHISOR::ISOR:: CANDIDATE:
,RPM WMMITGROUP:,.,LLQ,
A.Nevada limited.liability company
Ely: By:
Name: ame: A �45W Lem
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Title.
:KW RC CKET:F77Z FDD
C&NDIDATECONFIDMALBY AGREEMENT
FIRE MARSHAL'S OFFICE
Tozvn of Queensbunj
742 Bay Road, Queensbuny, NY 12804
"Home of Natural Beauty ... A Good Place to Live "
PLAN REVIEW
Rocket Fizz
1444 State Rt 9, Suite 8
CO-0278-2023
5/31/23
I have reviewed the submitted drawings for the above project; and offer the
following comments:
1) Verify Storage
2) Verify Fire Extinguisher's
3) Locks /Latches shall comply with 2020 NYSFC.
4) Verify operation of existing exit / emergency lights.
5) Verify paths of egress
6) CO Detection required
7) EVAC plan
8) Verify Knox Box Key
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Deputy Fire Marshal
Tyson Converse
742 Bay Road
Queensbury NY 12804
518 761 8205
tysonc@queensbury.net
Fi r e M a r s h a l's Off i c e • P h o n e: 518-761-8206 F a x: 518-745-4437
flremarshal@queensbunl.net - www.queensburJ.net