CO-0516-2023 a
CERTIFICATE OF OCCUPANCY ONLY office Use Only
APPLCATION—. Permit#:
l E C 0 V E P rmit Fee:$ bJ • a�
Tots of C`racnsbur}•
742 Bay Road,Queensbury,NY 12804 ®®
P:518-761-8206 or 518-761-8205 www. ujn voice#:
.net'U ? I�
TOWN OF QUEENSBURY
BUI-DING, CODES
"This application is for occup equiring a building permit"
BUSINESS INFORMATION:
Name of business: 1 9 S T L �'��� 1 3 C ,
Business Address (including suite,space, etc.):
Y
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 Marshals 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 oq C—a aG�
Applicant signature: Date: O.. 1 r2.3
Property Owner name: g, General Prop Mngr 08/22/2023
Property Owner signature: Da�.: _
Certificate of Occupancy Only Revised September 2022
Timm of C_rcvnsbun,
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): ib\X-,Vy— s Y\R-Y
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
• Business Owner(s):
Contact Name(s): K %n.►��:v►
Mailing Address, C/S/Z: i 'y�o �_�-� VSCA-4 �4-Y
Cell Phone: _( 4 i 2 ) 3 )l-2--_ o_2,�A Land Line: _( )
Email: .s5!,� C.� ?2 4 Y l rH
• Manager:
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line: _( )
Email:
• _Property Owner(s):
Business Name: L7---,- -rr),� v�
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _( )
Email:
Contact Person for Compliance in regards to this project: C)\n\\,\u
Cell Phone: Land Line: �)
Email:
Certificate of Occupancy Only Revised September 2022
Town of C zwensbun•
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: cS I C & 2
Business Name:
Business Location (including suite,space,etc.): lz ,,I
6 i
Business Phone#:
1. Business contact name: Kciy'd y)
Main Phone: econdary Phone:. W,
Contact is coming from what to n vl"llage.
2. Business contact name:
Main Phone:_( )_ ;Secondary Phone:_( )
Contact is coming from 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
302.8-1-47 CO-0516-2023
212 Smoke Shop
216 Quaker Rd, Suite 4
Certificate of Occupancy
EGO E OWE
l', AUG 18 2021 -r!.
FIRE MARSHAL'S OFFICE
Town of Queensbury
742 Bay Road, Queensbury, NY 12804
"Honce of Natural Beauty ... A Good Place .to Live "
PLAN REVIEW
Smoke Shop
212 Quaker Rd, Suite 4
CO-0516-2023
9/6/23
I have reviewed the submitted drawings for the above project; and offer the
following comments:
1) Verify Storage
2) Verify location of 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) Verify CO Detection
7) EVAC plan
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
{iremarsllal@queensbun!net www.queensbury.net