2024-0450 %- '- CERTIFICATE OF OCCUPANCY ONLY Office Use Only'% �' APPLICATION Permit#: � �
Q- -
kIr5-
-town of(jgccn.bury Permit Fee:
742 Bay Road,Queensbury,NY 12804 Invoice.#:
P:518-761-8206 or 518-761-8205 www.queensbury.net '
**This application is for occupancy only, with no work requiring a building permit**
BUSINESS INFORMATION:
Name of business going in to location listed below: i)� V 1`DCc N lr' ,
Business Address (including suite, space, etc.): EV- f -7 fikieea
(10-48-0P
Detailed explanation of business: 7ete-)r
— l'i.6 .
laciA ),,,,,,,,,,, w,,,v,
*** On a separate sheet of paper please provide an accurate layout of your
space showing all walls, exits, stockrooms, rest rooms, counters & fixtures ***
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: QJU yqn h' eknj
Applicant signature: -A;uk >' UY1 hMciill Date:
Property Owner name: AH....54-JV g`c M A.T- 1..._
Property Owner signature: ,4#;.� iSv j L. Date: 03-, ---V, --ti
Certificate of Occupancy Only Revised May 2024
'fowl of(jun n.bun•
742 Bay Road,Queensbury,NY 12804
P:518-761-8206 or 5181761-8205 www.queensbury.net
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE and INCLUDE AN EMAIL
• Applicant:
Name(s): % i (y
Mailing Address, C/S/Z: /¢3 —I‘ 5 n�SaYd 'fffruainy /13 rr
Cell Phone: ( ) Land Line: ( ) — 2.06v- to(/2,bk
Email:
• Business Owner(s):
Contact Name(s):)(;(,(M) Nati J
Mailing Address, C/S/Z: ilg' us ato_ep /u ry, /i/y /2g� Lf
Cell Phone: _( ) 977 ., --7 2- Land Line: ( ) -224 0 aeo
Email:
• Manager:
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _(
Email:
• Property Owner(s):
Business Name:
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _(
Email:
Contact Person for Compliance in regards to this project: Y)fl Shu Ai O.M
Cell Phone: ( ) Land Line: ( ) 3 41 Zo 4 . 48"
Email:
Certificate of Occupancy Only Revised May 2024
Town of(Lt«nsbu,,-
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: S ?� -
Business Name: ,a$9 bU.L&ty Spa- 4./Y
Business Location (including suite, space, etc.): 811) 5 2 Zol k
Business Phone#:
1. Business contact name: 2 1'1,C�
Main Phone:- — 2-64 _ kolo `a� ;Secondary Phone:
Contact is coming from what town/village? \U.S'n'V-('
2. Business contact name: ti-,At ,„ J
Main Phone: O'1, -_5 l t�'� �Z ; Secondary Phone:
Contact is coming from what town/village? A- \US\c k
TOWN OF QUEENSBURY FIRE MARSHAL'S OFFICE
P: 518-761-8205/8026 F: 518-745-4437
FIREMARSHAL@QUEENSBURY.NET
DEPUTY FIRE MARSHAL TYSON CONVERSE DEPUTY FIRE MARSHAL JOHN SCHADWILL
Certificate of Occupancy Only Revised May 2024