2024-0190 Office Use Only
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Town of Queensbury T `+
FIRE MARSHALS'OFFICE i '�'• '�
742 Bay Road,Queensbury,NY 12804 �- ' `?
518-761-8206 www.queensburv.net
FIRE MARSHAL SPECIAL PERMIT APPLICATION y=
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I Ta'�`S `fi Tax Ma ID#:
Project Location: p
Business Name,if applicable: ��le.�S e¢" /
Brief description of scope of project. 0 1 ��
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PLEASE SURE TO INCLUDE A SKETCH
SHOWING "f HE LOCATIOI�I OF
THE I RQPQSEI).WORK
OR PROJECT 0 .THR-�'ARa
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CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL '
• Applliiccaant__ CU/ Z ' =v >Fj
Name(s): � e_ C r ) �h 0►"i krf I e -
Mailing Address,C/S/Z: S-S- rin-c SDI' ' 6r - u/(.c_ J /2 ? 32 a
Cell Phone: S'S B 12 -7D$ 7 ( r/8 y 2 D -7 `' ,,:.
�_) Land Line: ) � 2 S a��-
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• Primary Owner(s): a:;
Name(s):
Mailing Address,C/S/Z: '' h
Land Line: ( )
Cell Phone: ( )
Email:
• Property Owner(s): �
Name(s): G S -2td CQ-^
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Mailing Address,C/S/Z: /5-2 ,j-..a,—_____ Ar, 0,,i
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Cell Phone: ( ) Land Line: ( .)
Email:
❑ Check if all work will be performed-by property-owner only,-----:. _
• Contractor(s): (List all additional contractors on the back of this form)
Contractor Name(s): _ __
Contractor Trade:
Mailing Address;C/S/Z:
Cell Phone: ( ) Land Line: ( )
Email:
**Workers' Comp documentation must be submitted with this application**
DECLARATION: ..
1. I acknowledge that no work shall commence prior to approval of a complete building
permit submission:. 30%of the fee is
2. If,for any reason, the building permit application is withdrawn,
retained by the Town of Queensbury: After 1 year from the initial application date,
100% of the fee is retained.
I have read and agree to the above: n/G ��
APPLICANT NAME.. 17145)"164 'e i kr- - C( l:I
APPLICANT SIGNATURE:
DATE: /�2-1--..Z/
PROPERTY OWNER NAM_ E:
DATE:
PROPERTY OWNER SIGNATURE:
FIRE MARSHAL'S OFFICE
Town of Queensbury
742 Bay Road, Queensbury, NY 12804
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"Home of Natural Beauty ... A Good Place to Live "
PLAN REVIEW
The Clever Cleaver
152 Sherman Avenue
2024-0190
FM Special Permit—Food Truck
04/25/2024
I have reviewed the submitted documents for the above project, and offer the
following comments:
1. Please provide a copy of the current inspection report for the hood
extinguishing (suppression) system from NYFS — *received 4/25/2024
2. Please provide a copy of the current inspection/cleaning report for the
hood system from K & B
3. Contact the office to schedule inspection of the vehicle (see email dated
4/25/2024 for details)
Deputy Fire Marshal
John Schadwill
742 Bay Road
Queensbury NY 12804
518 761 8206
schadwillj@queensbury.net
Fire Marshal's Office . Phone: 518-761-8206 • Fax: 518-745-4437
firemarshal@queensbury.net • www.queensbunj.net