CO-0728-2019 C E RTI F I CAT E 0 F OCCU PAN CY 0 N LY Offire Use Only,
Permit#., 2,0
APPLICATION ...............................................---- ------------------
Permit Fee.,
I nvolce W
742 Bay,Road, Queensbuq, NY 12804 ......... ................................................
P.,518-761-8206 or S18-761-8205 ww" q!g.............Lqp
"Thils, application, is ffor occupancyonly,, with no work requiring a building permit**
CONTACT INFORMATION:
Applicaft
N a me(s): Jv,
Mailing Address, C/S/Z.
III
A 51142 ( x Land Line:
Email:
AD-ak, (Lial, -------
4
e Bus,lness Owneds ,:
Contact Name(s)-
..............................
4
Mailing Address,, C/S/z 1
Cell Phone: J1 A-)-!n Land Line:
Emad.
* Man a,ger:
Contact Naime(s)-
Malling Address, C/S/Z.
Cell Phone:
Land' Line:
Email:
* Property Owner(SL",
Business Name'. MOA\
Con tact Name(s): ........... ....... ..........................................
Mailing Address,, C/S/,Z:
Cell Phon : Land Line:
Email:
Contact Person, for, Building & Codle Comphance:__
Cell Phone: Land Line:
Ernaill:
Cordfkate.of Octupancy Only Revised December 2017
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742 Bay Roan,Quelensbu'ry,NY 12804
P;' 19-7 1-,- r at 51 -761-82 r� r,`b
BUSINESS INFORMATION:
Name of business: �
Address (including suite, spaced. etc-)': -.I--' ( - Av tt A,-. AJL
Type of businiess (Le.: retail, car repair,,, etc®).
-re,-'t��A4
Please provide am a cnurate I ayout of yoiur st are sho i ng all wails, exits stockroorms, rest
rooms, counters and fixtures on a separate sheet of paper.
Ii PORA #T, The business, owner is responsible for keeping exits clear and maintlaining edit
si gns and emergency lights. Fire extinguishers, fire sprinkler systems, and fire alarm systems
require am mall 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 serni-annual inspections. Any,vio,lationsnoted!
during an ins e fi.o n require immediate corrective, action and a re-inspection.
Applicant name.
Applicant signature:
Date: L�t
°'
l
9irw cd ud 1 aYr
42 Day loan,Qveen buury, Y 12804
EMERGENCY CONTACT INFORMATION
"THIS FORM IS USED TO ASSIST EMERGENCY SERVICE PERSONNEL,,EIL 'WHO MAY, BE CALLED TO YOUR
BUSINESS AFTER HOURS., PLEASE BE SURE TIME CONTACTS, LISTED BELOW ARE WILLING AND
,AVAILABLE TO I EPSOND DURING OFF-HOURS TO ASSIST POLICE A,I'•IDJ R FARE PERSONNEL IN
GAINING ENTRY TOYOUR BUILINN .**
PLEASE BE,ADVISED THAT F IIILI.IIRE TO ASSIST EMERGENCY SERV11 E PERSONNEL MAY RE ILLT IN
DAMAGETO YOUR; BUILDING POLICEAND/OR FIRE PERSONNEL.
b�tr
Business Marne
A v
Busives5 Lac tti,o ,ir,aid thin( milt s space, etc.), �
Business Phony ��� .
1 Contact name:
Main, Phan .,. � µ �� �� Secondary Phone:
Coming from,what town/village?
. Contact name.
in,Phone,,_� � �,,m.. .... �Secondary Phone-
Coming from ghat town/villaR ?
TOW N F' 'UEEN S LtUFl Y F=IRE MA RSH A US 0 F11 C.
P: I -7 1-a2O,6 l"°':: 51 S.7,1, -4 7
FIRE MARSHAII, MI11 1'° PALMER DEPLITY FPoRE, MA,F S114AL,GARY STIII
i
FIRE 01"FICE
,PLAN REVIEW
Mini
578, Aviation Read.
1 / 2t
The following comments based on review of thesubmitted plans:
) Locks / latches i h ll comply with the 01. International .�iri e Code.
1+ire extinguisher location try be determined.
3) Verify, existing Exit / emergency lights,
Oary K. Stillman,
742 Bay Road
518 7161, 0
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MIMNY
578 Aviation
Certificate Of Occupancy Only,
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