CO-0720-2022 CERTIFICATE OF OCCUPANCY ONLY office use only
APPLICATION Permit#: Ce
Toxm of C ry
Permit Fee:$ I
742 Bay Road,Queensbury,NY 12804 Invoice#: 5(0_3tP
P:518-761-8206 or 518-761-8205 www.gueensbury.net
"This application is for occupancy only, with no work requiring a building permit"
BUSINESS INFORMATION:
Name of business: A4 M V r I Z-2,
Business Address (including suite, space, etc.): L-+ WtsfCV- 1 Ave,
/5011
Detailed explanation of business (attach a separate piece of paper, if necessary):
Ye4'ka,+6i - 0-/l�/hr s �f
1
***Please provide an accurate layout of your space 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.
Applicant name: � /�
Applicant signature: Date: 22__
Property Owner name:
Property Owner signature: Date: � .
Certificate of Occupancy only Revised September 2022
r
Town of Qirccnsbury
742 Bay Road,Queensbury,NY 12804
P:518-761-8206 or 518-761-8205 www.gueensbury.net
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): ' WIQt MIAs
Mailing Address, C/S/Z: fgqDbo
Cell Phone: "and Line. �)
Email:
• 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:_( rY1y ) 6-2`� ' O Land Line: _( )
Email: C) ft Y,G YY - k\ , C.8
• 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: aAnel n//
Cell Phone: Land Line:
Email:
Certificate of Occupancy Only Revised September 2022
ToHm a( ury
742 Bay Road,Queensbury,NY 12804
P:518-761-8206 or 518-761-8205 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 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:
Business Name: r
Business Location(including suite,space,etc.): 1n
r V v•
Business Phone#:
1. Business contact name: f�
Main Phone:_( -7 b ) & ~C Secondary Phone:_( )
Contact is coming from what town/village?
2. Business contact name: aI W Y ee LeJV_
Main Phone:_(570 ) qZ:�-)q I?��- ;Secondary Phone:
Contact is 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 TYSON CONVERSE
Certificate of Occupancy Only Revised September 2022
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309.11-2-36 CO-0720-2022 DEC o 5 20 22
BMILLZ TOWN OF QVEENSBURY
4 Western Ave S, Space F BUILD►NG& CODES
Certificate of Occupancy
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FIRE MARSHAL'S OFFICE
Town of Queensbunj
742 Bay Road, Queensbury, NY 12804
"Home of Natural Beauty ... A Good Place to Live "
PLAN REVIEW
BMillzz
4 Southwestern Ave, Space F
CO-0720-2022
12/6/2022
I have reviewed the submitted drawings for the above project; and offer the
following comments:
1) Verify Fire extinguisher locations & inspection.
2) Locks / latches shall comply with 2020 NYSFC.
3) Verify operation of exit / emergency lights.
4) CO Detection
5) Verify aisles & storage.
NOTE: A building permit is required for the interiors walls. This
must be completed and all Town of Queensbury inspections
completed, prior to any set up or occupation of the space.
Fire Marshal
Michael J Palmer
742 Bay Road
Queensbury NY 12804
518 761 8206
mikep@queensbury.net
Fire Marshal 's Office ■ Phone: 518-761-8206 - Fax: 518-745-4437
-flremarshal@queensburit.net - www.queensbunl net