CO-0046-2023 Sri CERTIFICATE OF OCCUPANCY ONLY office Use only
r Permit#: 0��0 - 20 Z
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Town ofCLK-rnsbury Permit Fee:$
742 Bay Road,Queensbury,NY 12804
U 2 202- Invoice �hh-N64
P:518-761-8206 or 518-761-8205 w w. EENSBURY
BUILDING&CODES
"This application is for occupancy nly, with no work requiring a building permit"
BUSINESS INFORMATION: A ���� '� �Qc� �� 13 Lf
10,140
Name of business: le C- 0,0C ' 10
Business Address (including suite, space, etc.): �71 QVZ7 ,,-
Detailed explanation of bus' ess (attach a eparate piece of paper, if necessary):
***Please provide an accurate layout of your space showing
all-walls, exits, stockrooms, rest rooms, counters and factures
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: .3 ,7
Property Owner name:
Property Owner signatur Date: 2/ 3
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Certificate of Occupancy Only Revised September 2022
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Town of CLnvns urp
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): � L-
Mailing Address, C/S/Z: �QA,,"6U L--
Cell Phone: ) ® Land Line:
Email: CQ!' 2 Sk n' CV" .F z-
• Business Owners
Contact Name(s): NA1
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _( )
Email:
• ' Manager:
Contact Name(s): Ar/
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _( )
Email:
• Pro ert Owner /�
Business Name: U9 pew 6 l
Contact Name(s): F Lf
Mailing Address, C/S/Z: O J` vz� tS v �✓
Cell Phone: _('V( to Land Line: _( )
Email: 0-o o o L-Vp-lrj
Contact Person for Compliance in regards to this project: 'J I",0 V
Cell Phone:L_) Land Line: �)
Email:
Certificate of Occupancy Only Revised September 2022
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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:
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Business Name: A&4-g C
Business Location (incl 'ng suite,space,etc.):
fo ( 6�� , Q(/4,/,j
Business Phone#:
1. Business contact name: z,
Main Phone:_(�) b 1 ;Secondary Phone:
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Contact is coming from what town/village? � rb1i/.1 D vt'
2. Business contact name:
Main Phone:_( ) ; 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