CO-0880-2021 atCERTIFICATE OF OCCUPANCY ONLY office use on►y
APPLICATION permit#: CG' ` t''2_Q21
Town of(Lwcnsbury Permit Fee:$ `
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742 Bay Road,Queensbury,NY 12804 Invoice#: 'Dot)
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: ` ,� � } Go'90
Business Address (including suite, space, etc.): t � �,�� l�
Detailed explanation of business (attach a separate piece of paper, if necessary):
CSD
***Please DEC 13 2021
Please provide an accurate layout of your space, showin
s TO OF QUEENSBURY
all walls, exits, stockrooms, rest rooms, counters nd TIMU &coDEs
` " ' " ' :i,:. <•; 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:
A licant si nature: ��% �� Date:
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Property Owner name: I rC,j I°`
Property Owner signature: r 'L✓� Dater
Certificate of Occupancy Only Revised December 2020
Town of(Lwensbury
742 Bay Road,Queensbury,NY 12604
P:516-761-6206or$16-761.6205 www.gueensbury.net
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s):
Mailing Address, C/S/Z: '(i,) \WeSV Movrdr—)n ( qve-e45
Cell Phone: 51sUA Land Line:
�6sl
Email:
• Business Owner(s):
Contact Name(s): ff
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: rr
---- Contact-Name(s): - - - - 1�CJ`�;- -- ------
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
Contact Person for Compliance in regards to this project:
Cell Phone: Land Line:
Email:
Certificate of Occupancy Only Revised December 2020
Totsm of(Luemsbuiy
742 Bay Road,Queensbury,NY 12804
P:518-761.8206 or S18.761.8205 www.gueensbury.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 T&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:
Business Name:
C avc�—r tr v,
Business Location(including suite,space, etc.):
Sup CLC,-w �
Business Phone#:
1: Business contact name: Gl en s�n
Main Phone: ; Secondary Phone:
-1 g9 /
Coming from what town/village?
2. Business contact name:
Main Phone: 4;Secondary Phone:
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 GARY STILLMAN
Certificate of Occupancy Only Revised December 2020