2024-0258 ACC
CERTIFICATE OF I ! ►, Fel► `� Use OM
APPLI i I WAY 2 8 2024 = �t :
Town o!Quccnsbur} --r it Fee:$ _
TOWN OF QUEENSBU..Ynv• ce#: .
742 Bay Road,Queensbury,NY 12804 BUILDING&CODES
P:518-761-8206 or 518-761-8205 www.queensburv.net
**This application is for occupancy only, with no work requiring a building permit**
BUSINESS INFORMATION:
Name of business: \\aL
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Business Address (including suite, space, etc.): ' ��)C Nke--
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Detailed explanation of business (a separate piece of paper, if necessary):
" ::10fiXeksLi k( 0 \(eC \f,A ,1 � �— e csh" rcii)e\n
cc ,. io ,e \o o c c \ riffc -
*Please provide accurate layout of your space shbwlng \
all walls, exits, stockrooms, rest rooms, counters and fixtures
on a se ate sheet of paper***
IMPORANT:The business owne1 responsible for keeping exi s 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: \INtAkVIN \\C\ULK
Applicant signature: \. Date: ' %c! . 2.3)2o2‘4i
441, OP
Property Owner name: r _A -
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Property Owner signature: WObi-ii 1� `S/'n,74KDate: irk2 , Z"O2p �Y g �
Certificate of Occupancy Only Revised September 2022
�G;ter` ,
Town of Qgcensbury
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
Name(s): \tk re\ \-\(\kLi.
Mailing Address, C/S/Z: SS C\rev `C� q\,,,as,4A,,,....) 92- 04
' Cell Phone: ( cg ) 2232_- Land Line: 4
Email: 'i-CC%� `�'�•CCU
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• Business Owner(s)•
Contact Name(s): 4.0 V1N•CXX
Mailing Address, C/S/Z: S` �,s,k"�e_ � Q iarr 1 `2
Cell Phone:_( St ) :21— 22.32. Land Oie: _( )
Email: \C. t.' (Cc,- Q...crrc&\.C.0"
_ • Manager:
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone:_( ' ) Landline: _( )
Email:
• Proper Owner01
Business Name: \ ka '� � e (�
Contact Name(s): Niciv� , ..,
Mailing Address, C/S/Z: S V> „ yr -f: iirb\cr1/4.%) 'OA ‘2104
Cell Phone:_ 2°� " Land Line: S
Email: c\&-d\,ir lln�`^CJ �fra • ccw
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Contact Person for Compliance in regards to this project: ^ ` te\
Cell Phone: ( 15\ ) �1K�•-2232 Land Line: ( %,` ) (on 22 '31_
Email:
Certificate of Occupancy Only Revised September 20223
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Town of Cjrccnsbury
742 Bay Road,Queensbury,.NY 12804
P:518-761-8206 or 518-761-8205 www.aueensburv.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: W.,..._.. .2..- J
Business Name: \\cLc
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Business Location(including suite,space,etc.): L\30 1 ik Ne '
Q2.9.Q3ti\DQ( .\ \., Tz6 04(‘14-- \-2-5btsi . '
Business Phone#: 1 Oa '
1. Business contact name: Vp 0 tr. \\04.34..X
Main Phone: (. Z ) ` 0% ` 223 ..Secondary Phone:_( S\K ) .-)CA— 52.,SS
Contact is coming from what town/village? Q.\.9-09-M\0.)S s :____
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2. Business contact name: C�.‘ ���
Main Phone:_( '5\\ ) \% —Ma Secondary Phone:_ .5T ) eP 44
Contact is coming from what town/village? Ck_kli Q.SI.Si _____)
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
Town of Queensbury
� 742 Bay Road, Queensbury, NY 12804
"Home of Natural Beauty ... A Good Place to Live "
PLAN REVIEW
Haux Nest Bread
430 Dix Ave
2024-0258
5/29/24
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 Smoke Detectors
Deputy Fire Marshal
Tyson Converse
742 Bay Road
Queensbury NY 12804
518 761 8205
tysonc@queensbury.net
Fi re Marshal 's Office • Phone: 518-761-8206 • F a x: 518-745-4437
firemarshal@queensbury.net • www.queensbury.net