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=CERTIFICATE OF OCCUPANCY ONLY|office use oniy C0-o1sq-vlAPPLICATIONvermin CO~OT SY Rel7S000vonicinerermrees_L00.o AMNESNBSNO JO oid t:__2ZVO742BayRoad,Queensbury,NY 12804 AfP:818-761-8206 or 518-761-8205 www.queensbu nt 6102 $+AON t **This application is for occupancy only,withna work+ul ing a building permit** CONTACT INFORMATION: ©Applicant: Name(s):SfeMhent Ww.ass Ww Mailing Address,C/S/Z:Go GG..weed Aus Qreewshen iy (2504 Cell Phone:(S7#_)_36/-2357 land Line:(S7@_4 793 =27736 Email:Stephene Basso DPT.Com «Business Owner(s): Contact Name(s):_Sferthene _«,Bassar PT PC Plytrel Thenays,a fabhih Mailing Address,C/S/Z:_60 ¢G.woel jus Qusenthen nig 2HCellPhone:(SVK _)36/7 -23F4 landline:_(_S7@)793-773 Email: «Manager: Contact Name(s): Mailing Address,C/S/Z: Cell Phone:_()Land Line:_() Email: ¢Property Owner(s) Business Name:we Contact Name(s):Zolewt Goves— Mailing Address,C/S/Z:_9 tod Cres?Dax Queens &.ny (26ey Cell Phone:_(7y¢-)307 ~3356 Land Line:(S7F )_793=3 3-6 Email:, Contact Person for Building &Code Compliance:StePhew Basse Cell Phone:_(S/)_36/-238%Landline:(SVF)__773-773 € Email:Stether@®fbossic PPT.Com Certificate of Occupancy Only Revised December 2017 Ton ef Queensbury 742 Bay Road,Queensbury,NY 12804 P:518-761-8206 or 518-761-8205 www.queensbury.net EMERGENCY CONTACT INFORMATION **THIS FORM IS USED TO ASSIST EMERGENCY SERVICE PERSONNEL WHO MAY BE CALLED TO YOUR BUSINESS AFTER HOURS.PLEASE BE SURE THE CONTACTS LISTED BELOW ARE WILLING AND AVAILABLE TO REPSOND DURING OFF-HOURS TO ASSIST POLICE AND/OR FIRE PERSONNEL IN GAINING ENTRY TO YOUR BUILDING.** PLEASE BE ADVISED THAT FAILURE TO ASSIST EMERGENCY SERVICE PERSONNEL MAY RESULT IN DAMAGE TO YOUR BUILDING BY POLICE AND/OR FIRE PERSONNEL, pate-__({1S /2or$ business Name:_§L0Phert w Basse PT Pe.My steal Thera,adPebblelo Business Location (including suite,space,etc.):60 ¢Cawood.Ann Qereres hey Ny(2hoy Business Phone:S/&793-P/3C 1.Contact name:S Fe/hene—PP S5ebr Main Phone:(SUE)293-_TYP Secondary Phone:GEE)FE/-2F FSSTFComingfromwhattown/village?_Q reenss 4 e Ace. 2.Contact name: Main Phone:_();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 2017 296.19-1-1 C€0-0754-2019 Dr Stephen W Bassin Tem of Qucensbury 60 Glenwood Ave 742 Bay Road,Queensbury,NY 12804 Certificate of Occupancy Only :518-761-8206 or 518-761-8205 www.queensbury.net BUSINESS INFORMATION: Name of business:5 terhen w.Basse PT PC.Pligsial thay Pebcblh, Address (including suite,space,etc.):_GQ 64,wood tre Quaeresh,Ny (2¢/ Type of business (i.e:rétail,car repair,etc)WMedia /afr (Ph sia Theres ) Please provide an accurate layout of your store 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:S bePhenr B aw SSA ' Applicant signature: Date:fis 2215 Certificate of Occupancy Only Revised December 2017