CO-0716-2023 T.
CERTIFICATE OF OCCUPANCY ONLY Office use Only
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APP ADNa
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Town of(�uccnshury `
742 Bay Road,Queensbury,NY 12804 NOV ® 7 nvoice#: 6
P:518-761-8206 or 518-761-8205 www.• eey..1i . -
OF
BU/LbING ENScopSURY
**This application is for occupancy only, wit --r�o-w k requiring a building p ermit**
BUSINESS INFORMATION:
Name of business: ,C () a`Me-
Business Address (including suite, space, etc.): t'\ Cnv.V� U11 &rn 0.��-
fir, -ii2 '1,,,�- 4 //or A,' /28o9
Detailed explanation of business (attach a separatepiece of paper, if necessary): P
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***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.
viApplicant name. £i9 � //r-fr---,c,tfr, c,4._ .
Applicant signature: ^ Ja2' Date: r / 7 2.7
Property Owner name: ,s,� «�A. �j�G�
Property Owner signature: 2 !/ --Date: /G 7 .43
Certificate of Occupancy Only Revised September 2022
Town of Clnctnsbun•
742 Bay Road,Queensbury,NY 12804
P:518-761-8206 or 518-761-8205 www.queensbury.net
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant: r
Name(s): �:/C ,1* Cjt7' �, //eve700
Mailing Address, C/S/Z: 176 ,?PaJ f, tci' i--��� , Y /mod,''
Cell Phone: ( S70 ) .ecl c7_ O ft7 Land Line: CPS ) J O — // o
Email:
• Business Owner(s): (---
Contact Name(s): c,) a / f�`f 7---7 'e_
Mailing Address, C/S/Z: ? 76 ,J�1-OcL. .T-1�ee '2 W e• iTegz
Cell Phone: _(YTO ) YG/G - G,S 962 Land Line: _( 5W )$(Y -- /76/0
Email:
• Manager: `
Contact Name(s): ✓�s1 Imo, 11/1-7z-e/ 0r12 ,-'/Iet
Mailing Address, C/S/Z: I fir-ee 7L Wafp-101-- , * I4 '9z-
Cell Phone: ( s�'7C7 ) 21G -- 03 '90 Land Line: _( .5`'/5 ) ,SDY' /(c7c )
Email:
• Property Owner(s):
Business Name: 4/At/ /141.� LL e—
Contact Name(s): ,, j&c C�0,17ce11v
Mailing Address, C/S/Z: 2 97 Sfr -4 ,e Jo 6 k.j Tai/s / 03
Cell Phone: _( ,SiQ ) .54 a_Le l'1 Land Line: (Vp ) 7 yd._ 9
Email: SK,Ie c7 l(ele/ (7Ot4
Contact Person for Compliance in regards to this project:
Cell Phone: ( ) Land Line: ( )
Email:
Certificate of Occupancy Only Revised September 2022
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Town of C rccnsbury
742 Bay Road,Queensbury,NY 12804
P:518-761-8206 or 518-761-8205 www.queensbury.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: 11..., 7, 2
54",L2,
Business Name:
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Business Location (including suite,space,etc.): q— �0�)�� itlycjierli Avc
So 6 'aid. -- a l/d"` ,./i/ Y l e e'o y
Business Phone#:
1. Business contact name: c%c/y/(ie f 1/7 A--...-7erfryek
Main Phone:_(" 70 ) S7 O- O3 / v;Secondary Phone:_( )
Contact is coming from what town/village? WelC'Ofr? Z //cam
2. Business contact name: ��.<` lf' ( ,-7 he C C -
Main Phone:_(,S/ ) —2 fa ?P`IZ_ ; Secondary Phone:_(S j) )_3( / �&. I,
Contact is coming from what town/village? 9(, e-,.j 4—d___.
TOWN OF QUEENSBURY FIRE MARSHAL'S OFFICE
P: 518-761-8206 F: 518-745-4437
FI R EMARSHAL@Q UEENSBU RY.N ET
FIRE MARSHAL MIKE PALMER DEPUTY FIRE MARSHAL TYSON CONVERSE
1
Certificate of Occupancy Only Revised September 2022
FIRE MARSHAL'S OFFICE
Town of Queensbury
742 Bay Road, Queensbury, NY 12804
"Home of Natural Beauty ... A Good Place to Live "
PLAN REVIEW
5 N Dime
4 Western Ave S, Suite 2
CO-0716-2023
11/15/2023
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 existing exit/ emergency lights.
4) CO Detection
5) Verify Knox Box key.
6) Verify aisles & storage.
D� Cen.A4A..az
ty Fire Marshal
Tyson Converse
742 Bay Road
Queensbury NY 12804
518 761 8205
garys@queensbury.net
Fire Marshal is O f f i c e • P h o n e: 518-761-8206 • Fax: 518-745-4437
firemarshal@queensbury.net • www.queensbury.net
309.11-2-36 CO-0716-2023
5 n dime
4 Western Ave S, Suite 2
Certificate of Occupancy
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