application CERTIFICATE OF Occ- PA114cY r L m ;o#ice Use Only
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742 Bay Road,Queensbury,NY 12804 TOWN OF OUEENSBUR " Invoce# 1
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P:518-761-8206 or 518-761-8205 www. ue sbur UILGt41' G&COL'E _,_„-...,.1
**This application is for occupancy only, with no work requiring a building permit**
CONTACT INFORMATION:
• Applicant: 1' 1 1
Name(s): upS6W (ebdwA-1eQS geAl#, AfeLo k
Mailing Address, C/S/Z: 9 CaR2 ROAD QUP$4/6"b i2 i2 U
Cell Phone: $i$ ) 8' 2 ' I Z Land Line: '( silr ) F2 -W 22.
Email: j i 1 C CO P P] i C @ 1104 , oe
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• Business Owner(s):
Contact Name(s): Q\ c ��
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: _( )
Email:
• Manager:
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _( )
Email:
• Property Owner(s):
Business Name: A ?\; ccL.r r
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _( )
Email:
Contact Person for Buil 'ng& Code Compliance:--�1 MC •}L'�'``
Cell Phone: (S'!'l ) DI Z ' 12'l 1 Land Line: ( )
Email: e-cop m�c,.. e titiN.13 R.. G
Certificate of Occupancy Only Revised December 2017
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742 Bay Road,Queensbury,NY 12804
P:518-761-8206 or 518-761-8205 www.oueensbury.net
BUSINESS INFORMATION:
Name of business: I-11)0,56N HPAdw1 e25 Neagli AiC-ttAI dek
Address (including suite, space, etc.): 27 Cgee ►�o�v
y
QveeQcbJ1 Ny 12 o I
Type of business (i.e.: retail, car repair, etc.): Mem cc Nl°uttAGDIf�
Please provide an accurate layout of your store 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.
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Applicant name:
Applicant signature: cq4,
Date: ) Z6-1
Certificate of Occupancy Only Revised December 2017
742 Bay Road,Queensbury,NY 12804
P:518-761-8206 or 518-761-8205 www.queensburv.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:
/4
Business Name: LIUOJON 1Ie4DWP4'QS llral1'Ii Nc- wo ?k
Business Location (including suite,space,etc.): 21 CaQ 6P.0
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Business Phone#: c( 0 7 / 03Od
1. Contact name: J,M 4cememicie
Main Phone:_( SI7 ) 8I (. ' 1 211 ;Secondary Phone:_( JI 0 ) 0j� -Wit
Coming from what town/village? Qvteus.10
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2. Contact name:
Main Phone:_( ) ;Secondary Phone:_(
Coming from what town/village?
TOWN OF QUEENSBURY FIRE MARSHAL'S OFFICE
P: 518-761-8206 F: 518-745-4437
F!REMARSHAL@QUEENSBURY.NET
FIRE MARSHAL MIKE PALMER DEPUTY FIRE MARSHAL GARY STILLMAN
Certificate of Occupancy Only Revised December 2017