CO-0717-20237
„ ir---- CERTIFICATE OF OCCUPANCY ONLY Office Use Only -
Permit#: CD
AP IC° ATI!Q' •E r
lc wn of(tirecn.thwy E., - +4.- Permit Fee:$ 20�' "2'
742 Bay Road,Queensbury,NY 12804 NOV 07 2023 Invoice#: 6/11 b
P:518-761-8206 or 518-761-8205 www.que n bury.net
TOWN OF QUEENSBURY
BUILDING&CODES
**This application is for occupancy only, with no work requiring a building permit**
BUSINESS INFORMATION:
Name of business: c:"`Nt, N �'` �'`e'
Business Address (including suite, space, etc.): �`� l rz /
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Detailed explanation of business (attach a separate piece of paper, if necessary): -T�1,1
***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: '--Ez,o.i-" 7 17 /4'4.-7cffr794 -
Applicant signature: Date: il. 7.-0)
Property Owner name: 4i�
Property Owner signature: L______----
I,*6 Date: (r" 7/Z3
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Certificate of Occupancy Only Revised September 2022
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Town of CIRcensbun:
742 Bay Road,Queensbury,NY 12804
P:518-761-8206 or 518-761-8205 www.queensbury.net
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:Name(s): of cc e.e,-perk_am- Ae.,,ynante.7__
Mailing Address, C/S/Z: f7 6. k- /f -1 Woiv -4 �� / � 2
Cell Phone: (5-7a ) 3'1O— OJ eY0 Land Line: ( )
Email:
• Business Owners): j v //efr_x/ce._,,, c--z _
Contact Name(s): c-e -,�e
Mailing Address C/S/Z: 77( /ic0 �>-i,',-� 0� i/y � /�e2_
Cell Phone: _( 7 ) IQ°—(2.1 9 O Land Line: _( )
Email:
• Manager:
Contact Name(s): �a'`'lf-'e. / //:(1-i'?'‘/z-'7'-'4 r�
Mailing Address, C/S/Z: ? 76 40i c?cc :%�1--e� V t - —4, 4) /c
Cell Phone:_(<70 ) !9'(0 —a-rq Land Line: _( )
Email:
• Property Owner(s):
Business Name: , rot ci , p t c2 r,
Contact Name(s): ,tC�,k-v L-c-, ,.J 6/if
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Mailing Address, C/S/Z: "_ ;�� . tie
Cell Phone. _( 9 a- ) 7l c `ZZG Z Land Line: _( 5 l &' ) 1 r� O C
Email: /h)ti (-.c 1s- 6 je,..e..I ,Lc)-N
Contact Person for Compliance in regards to this project:
Cell Phone: ( ) _Land Line: ( )
Email:
Certificate of Occupancy Only Revised September 2022
p
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Town of(`reensbury
742 Bay Road,Queensbury,NY 12804
P:518-761-8206 or 518-761-8205 www.queensbury.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:5, diptie
Business Name:
Business Location (including suite,space,etc.): ?...51i r �/�'
tit,/ Z -
c e4=I4 5 wP-y UU0'01
Business Phone#:
1. Business contact name: SPE/t/e. � //se (1,--`Se"
Main Phone:_( V ) 240 ` U/®Secondary Phone:_(
Contact is coming from what town/village? /7 6e; Gl 64v--
2. Business contact name: AAA (2r7c_(
Main Phone:_(5( (!r- ) 62 Secondary Phone:_( s1 Y ) 74 C— LZc 7
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
FIRE MARSHAL'S OFFICE
11111111.1411 Town ofQueensbury
742 Bay Road, Queensbury, NY 12804
"Home of Natural Beauty ... A Good Place to Live "
PLAN REVIEW
5 N Dime
959 State Route 9, Space ZZ
CO-0717-2023
11/15/2023
I have reviewed the submitted drawings for the above project; and offer the
following comments:
1) Verify Fire extinguisher locations & inspection.
2) Locks /latches shall comply with 2020 NYSFC.
3) Verify operation of existing exit / emergency lights.
4) CO Detection
5) Verify Knox Box key.
6) Verify aisles & storage.
•
7�� C�� .0.11.
Deuty Fire Marshal
Tyson Converse
742 Bay Road
Queensbury NY 12804
518 761 8205
garys@queensbury.net
Fire Marshal 's Office • Phone: 518-761-8206 • Fax: 518-745-4437
firemarshal@queensbury.net • www.queensbury.net
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