CO-0826-2021 CERTIFICATE OF OCCUPANCY ONLY office Use On-hi
Permit#:Co -0 bZb -20 21
APPLICATION
To will of Quirnatiutys Permit Fee:
.742 Bay Road;.Queensbury,NY' 12804
Invoice#•
0:518-761-8206 or 518-761-8205 =nj
NOV 6 2021
*This application isfor- ancy-onl n ork requiring a building permit** .
TOWN OF QUEENSBURY
BUSINESS INFORMATION: BUILDING&CODES
Name of business:
Business Address (including suite, space, etc:):
_Detailed_explanation of business (attach a separate piece of paper, if necessary):
A)
\j
***Plese Orovidt at,w � YM. of YOW XP$Ce, :shoes`
w ails, e�utsj S>t0� �0W. Deft ra�msj
bilk &s p ate shut of piper*
IMPORANT:The business:ow- ner 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:
Applicant signature: Date:
Property Owner name: Yv i
Property Owner signature: Date: 1
Certificate of Occupancy Only Revised December 2020 .
ft
742 Bay Road,Queensbury,NY 12804
P:.518-761-8206 or 518-761-8205 www.gueensburv.net
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
•. ApRWIcant:
Name(s):. .
Mailing.Address,
Cell.Phone: _) = Land Li : _( 4 )'7i,9& � 1
Email: jr
• Business Owner(s):
Contact Name(s):
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: . pp��c.o.,- �
Contact Name(s): -
Mailing Address; C/S/Z: .
Cell Phone: Land Line: _( )
Email:
Contact.Person for Compliance in regards to this project�ee.
Cell phone: ( Sig- ) Land Line: I 15tk- 1
Email: -f-A.)�Beyep ejli 'i
Certificate of Occupancy Only Revised December 2020
r
r
I
Town of(Li eem.bury
742 Bay Road,Queensbury,NY 12804
N 518-76178206 or 518-761=8205 www:queens bury.net
EMERGENCY CONTACT INFORMATION
*THIS FORM IS USED TO ASSIST EMERGENCY SERVICE PERSONNEL WHO MAYBE 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
DAMAGETO YOUR1BUILDING BY POLICE AND/OR FIRE PERSONNEL.
Date:
Business Name:
Business Location(including:suite;space,etc:):
y
Business Phone:#:
1.. Business contact name: y [o �14 -S
-Main Phone: Seconds Phone:_ w '3.14
Coming from what town/village? .
2.: Business contact name:
Main Phone:._( L ;Secondary Phone:_( )
Coming from what town/village?
TOWN OF Q.UEENSBURY FIRE MARSHAL'S OFFICE
P:518-761-8206 F:518 745-.4.437
FIREMARSHALOQUEENSBURY.NET
FIRE MARSHAL MIKE PALMER DEPUTY FIRE MARSHAL GARY STILLMAN
certificate of Occupancy Only- Revised December 2020