application `�- CERTIFICATE OF OCCUPANCY ONLY . Office Use Only
_ APPLICATION Permit#: CO— 0(
Town of Cluccnsdiury
Permit Fee:$ lap
o
742 Bay Road,Queensbury,NY 12804 Invoice#: `Z�
P:518-761-8206 or 518-761-8205 www.queensbury.net
**This application is for occupancy only, with no work requiring a building_permit**
CONTACT INFORMATION:
• Applicant:
Name(s): Behavorial Health Services North, Inc.
Mailing Address,C/S/Z: 22 US Oval, Suite 218, Plattsburgh, NY 12903
Cell Phone: (215 )565-6875 Land Line: (518 )563-8206
Email: mlukens@bhsn.org•
•
Business Owner(s):
Contact Name(s): Mark Lukens, President& CEO (non-profit organization)
Mailing Address, C/S/Z: 22 US Oval, Suite 218, Plattsburgh, NY 12903
Cell Phone:_(215 )565-6875 'Land Line: (518 )563-8206
Email:mlukens@bhsn.org
•
• Manager:
Contact Name(s): Mark Lukens
Mailing Address, C/S/Z: _22 US Oval, Suite 218, Plattsburgh, NY 12903
Cell Phone:_(215 )565-6875 Land Line: _(518 )563-8206
Email:mlukens@bhsn.org
• Property Owner(s):
Business Name: Schermerhorn Holdings
Contact Name(s): Richard Schermerhorn
Mailing Address, C/S/Z: 536 Bay Rd, Suite 2, Queensbury, NY 12804
Cell Phone:_( ) Land Line: _(518 )798-0674-
Email:npalmer@schermerhornholdings.com
Contact Person for Building & Code Compliance:Mark Lukens
Cell Phone: ( 215 )565-6875 Land Line: ( 518 )563-8206
\ Email: mlukens@bhsn.org
NOV 0 6 2020
Certificate of Occupancy Only evised S ptember 2020.
TOWN OFOIJEENSBURY
BUILDING&CODES-
Torn of OyeeIL hury
742 Bay Road,Queensbury,NY 12804
P:518-761-8206 or 518-761-8205 ww N.Oueensbury.net
BUSINESS.INFORMATION:
Name of business: Behavorial Health Services North, Inc.
Address (including suite, space, etc.): 25 Willowbrook Rd, Suite 2, Queensbury,NY 12804
Detailed explanation of business (attach a separate piece of paper, if necessary):
Not-for-profit behavioral health care provider(mental health and substance clinical services)
***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: Mark Lukens, President& CEO
Applicant signature: ,,,,� ��i Date:. 11/06/2020
Property Owner name: - Cr-VA SeirGrr -12Ancl(Ne-.1 .
Property Owner signature: / ��, / ` Date: I / OO
Certificate of Occupancy Only Revised September 2020
•
t �'
Town of C rrrnsbury
742 Bay Road,Queensbury,NY 12804
P:518-761-8206 or 518-761-8205 www.queensburv.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: 11/06/2020
Business Name:Behavorial Health Services North, Inc.
Business Location (including suite,space,etc.): 25 Willowbrook Rd, Suite 2, Queensbury, NY 12804
Business Phone#: (518) 926-7100 or (518) 563-8206
1. Business contact name: Susan McManus
Main Phone:_(518 ) 813-7067 ;Secondary Phone:. (518 )926-7100
Coming from what town/village? Glens Falls
2. Business contact name: Jennifer Hill
Main Phone:_( 518 ) 542-6667 ;Secondary Phone:_(518 )926-7100
Coming from what town/village? Queensbury •
.1
TOWN OF QUEENSBURY FIRE MARSHAL'S OFFICE
P: 518-761-8206 F: 518-745-4437
FIREMARSHAL@QUEENSBURY.NET
FIRE MARSHAL MIKE PALMER DEPUTY FIREMARSHAL GARY STILLMAN
Certificate of Occupancy Only Revised September 2020,