2024-0385 Office Use Only
Permit#: 21)241c- 1p5acj FIRE MARSHAL SPECIAL
Permit Fee:$165.00 • PERMIT APPLICATION
Invoice#: � �'�,.:?xa�P '7",
Reviewed by:
Office of the Fire Marshal Hinz L f r h ll
742 Bay Road, Queensbury,NY 12804 •
518-761-8206/8205 www.queensbury.net
Project Location: 1500 U.S ..9, L WE GEORGE; N'f Tax Map ID#: (288 v!a - (- Lc-
Business Name,if applicable: FA Nay �GoTWefit CcNTEJZ '
n Fireworks display Sprinkler Install ❑ FA Install ❑ Fuel Tank Removal
/Other: C20 x(201' TEW'T" SKE - ell 8/3
Scope of project:
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JUL 3 0 2U14 I E
TOWN N ®,- OUEENSBURY
FM Special Revised 6/2024
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): MPctr guR DICK
Mailing Address, C/S/Z: I S00 U•S.q , LEA@t G oR E , NY (OP.'S--
Cell Phone: 518 ) 142?- 4'760 Land Line: ( SIB ) 17q8-g65g
Email: hna'ik. rdZck -caanZ -ccdl- c'cefr6 r. can
• Business Owner(s):
Name(s): j..,AuQ 1 FE 5
Mailing Address, C/S/Z: l070 Noerisioe. Pg. , .8&No(NGTo0, v-r 05a01
Cell Phone:_( goa ) a 36 - 9S3i, Land Line: _(e02 ) 6 8l - '76 3/1
Email: :ly-�«ctwearcerc ec.Cotr%
• Property Owner(s):
Name(s): t oRDo W Co N`P f' f
Mailing Address, C/S/Z: So STPrc.E st: 6V 1c.aa2, RL$i 'f I N1L /276,7
Cell Phone:_( ) N j Land Line: _(‘(6 ) (f a.- 9€(I
Email: Co miners al Ca 9octioryfte uelrf Arne. net
• Installer/Contractor: Workers'Comp documentation must be submitted with this application
Contact Name(s): T(P� - TENT
Contractor Trade:
Mailing Address, C/S/Z:.
Cell Phone:_( ) Land Line: _( )
Email:
DECLARATION:
1. I understand that no work shall commence prior to approval of a complete Fire Marshal
application submission.
2. If,for any reason,the Fire Marshal application is withdrawn,30%of the permit fee is retained by
the Town of Queensbury.After 1 (one)year from the initial application date, 100%of the fee is
retained.
I have read and agree to the above:
APPLICANT NAME: RPOC' r ccI
APPLICANT SIGNATURE: ' `r off‘ DATE: fit'
PROPERTY OWNER NAME: GL�u J(a4?N- l�S
PROPERTY OWNER SIGNATURE: SE Al-rate-ID Ler�r., DATE:
FM Special Revised 6/2024
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1500 U.S. 9, Lake George, NY 12845
Ph: 518.798.9658
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C'E RTIFIIC� T/�. CIF FLAME RESISTANCE J ,
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- Issued by Eureka! Tents =• t'''
S.•, A div. of Johnson Outdoors Gear, Inc. r. ..„'" ..b
-,, ; ° 625 Conklin Road .
rf Binghamton, NY 13903 {
r`� '' (800) 235-2607 }y b.
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; . Company Name: T-l-�m{ cDc)A- l)Ccc,( Cep fry• ,..
''.:. Address: I SZ`o 2.,.t,4 Uj .. ;,_
,_.p}\ City/State/Zip): La L-e- CiZ''�,,--c`e I\]Y 12--R.HS
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L , ;'>.,,: This is to certify that the products herein have been manufactured from material flame-retardant and
9 „..' inherentlynonflammable as here after specified bythe material supplier. '. _: .
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s. ' See page 2 for supplier and fabric information.* z
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,rj ; Description of tern (s): Date of Manufacture: - . r �`,fi
2410222 PARTY CNPY 20X20 Y/W (Made in USA) Sep 2019 ,,,• „ J
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I: ;\ Certification is hereby made that: The articles described on this certificate have been manufactured with flame-retardant
fabric or material registered and approved by the California State Fire Marshal. The fabric ias been tested and passes the
'�� following (current and previous) codes: NFPA-701 and CAN/ULQ-S109*.
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}' ' \ THE FLAME RETARDANT PROCESS USED WILL i`' til' '
f` ;' REMOVEDBY WASHING AND)IS ttm x'2�" 'g.+x• .....L ~ �
NOT BE REMO E ,. '- ;�11 >.•
' `t';,c t`Ak = ; ' Tim Andersen,Vice President "/
`. EFFECTIVE FOR THE LIFE OF THE FAB"IC. ,,,,, ,'_
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