2024-0151 CERTIFICATE OF OCCUPANCY ONLY Office Use Only
Permit#: 6�LI — ) 1 51
APPLICATION
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Town of Qucenshury I{
Invoice#:
742 Bay Road,Queensbury,NY 12804 �AR � �°P �� •
P:518-761-8206 or 518-761-8205 www.queensbury.net
TOWN N OF
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**This application is for occupancy only,with no work requiring a building permit**
BUSINESS INFORMATION:Name of business: ( �. V__zrkk
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Business Address (including suite, space, etc.): 2/ te�-s" /'oa, Qoe_eorbv-ty
Detailed explanation of business (attach a separate piece of paper, if necessary): Y1201
out, CO h U 7l''
***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: R err pGkWG// ( ' ' 1%6 elf?gebta/ DS�
Applicant signature: , , _ Dater
Property Owner name: t47/tarla1 U/-7! Vesd_hs/ aihdre 4 ,-2//or1 dr� 1-Ir , /1s
Property Owner signature: Date:
Certificate of Occupancy Only Revised September 2022
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Town o£fhrcenabury
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): �;6c,74 -ac/C4 �/
Mailing Address, C/S/Z: /?' Z.--e,G'.&n e_. Ge/7 c �a//-sj /Vy / /
Cell Phone: (,_c/) 716-rcf-7- ' Land Line: ( • )
Email: / --)fl-e_Akie//J7 g',f� 2:772 &/7' co-0-7
• Business Owner(s):
Contact Name(s): ;1 rnb&-f y B V/c&,'
Mailing Address, C/S/Z: 1 I Irk_.ai hcS ri--. ()V.PD VI`sitj M( ( 2 o4
Cell Phone:_( 57 9) "14 4 SS S Land Line: ( it.) 824 - II 1 9
Email: Y__A vNnbrny irec& l-k2(ry\e . c r Ivy\
• • Manager: . •
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: _( ) 0 Land Line: _( )
Email:
• Property Owner(s):
Business Name: Jffl7 /'7V7 Ut4ttersa/is7 or,I�dZ7/d ri � 'Le>"c/d//S
Contact Name(s): ,�ohY.T JZc>c/ c�cl/ C/fa' - v1/c/%7d..c c rci,iciri v CS OP:
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Contact Address, C/S/Z: / `ocon ii-ve /ems . //s Of'/z(Q/ �f
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Cell Phone: _( v) ‘ -9P7 Land Line: ( ) an iCItc� 2�
Email: �6Pv-T f'4eKc //1737� 7h // �'D rn t v i ! -(-5 /gY (U/
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Contact Person for Compliance in regards to this project: Rofr,T / 9C, /Gll
Cell Phone: ( i.c:(') o - 9'tr 7-7 Land Line: ( )
Email: /^0/30T f oG/ec✓G// 937/17ynr9i/eci P1
Certificate of Occupancy Only Revised September 2022
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I-01471 of{Lircrnabury
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: 3`2 s — 2 i
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Business Name:�� ( CL-(k1
Business Location (including suite,space,etc.): 'E A(4e 0 ( :. : W-,,,,n>
Business Phone#: ' a 2'{- 1 I n
1. Business contact name: 1K 1v e v ' jd G_r—C
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Main Phone:_( 'b ) �2't 1( (( ( ;Secondary Phone: ( 6-70 ) 7 LfL 3S-5 5
Contact is coming from what town/village? cvA-e cv‘51,ow1
2. Business contact name: 1
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
011101k FIRE MARSHAL'S OFFICE
. Town of Queensbury
742 Bay Road, Queensbury, NY 12804
"Home of Natural Beauty ... A Good Place to Live "
PLAN REVIEW
Legacy Nine Realty
21 Weeks Road
2024-0151
3/28/2024
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 aisles & storage.
Deputy 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
fcremarshal@queensbuny.net • www.queensbury.net
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