CO-0221-2021 - CERTIFICATE OF OCCUPANCY ONLY office use only
APPLICATION Permit
Permit Fee:$
742 Bay Road,Queensbury,NY 12804 Invoice#:
P:518-761-8206 or 518-761-8205 www.gueensbury.net
"This application is for occupancy only, with no work requiring a b ' ' g;
BUSINESS INFORMATION: L�qC
Name of business: f�z /V' , u" or— 1L1c,� CQ�Business Address (including suite, space, etc.): ts�� kDetailed explanation of business (attach a separate piece of paper, if necess�it( Wi'h. Mvikh 4- 6 i&#-)s , � i ecJlOc+� oJ � +o
***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: '&J-N' �
Applicant signature: Date: I tL Zc�
Property Owner name: C A(' )sgto s�,k {2,j'k. 9 I.LC
Property Owner signature: Date:
p Y g
Certificate of Occupancy Only Revised December 2020
-16
"ITciwii if Qaiti i hiui';
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 MAYBE 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: 4
Business Name: -Tl,..X— YY\0\n% Lh �tr �q� („eo
Business Location(including suite,space,etc.): ,��5 S\xA-r_ \Rd 11%' Ct
Business Phone#: 5k`b_ _1 kZ-0-i'l` k
1. Business contact name: C'VJ_
Main Phone: ;Secondary Phone: 5\iC--L_& Z -256 1
Coming from what town/village? GJkc^nswo
2. Business contact name:
Main Phone: ;Secondary Phone: 5\%.— q3z
Coming from what town/village? f ex S
TOWN OF QUEENSBURY FIRE MARSHAL'S OFFICE
P: 618-761-8206 F: 518-745-4437
FIR EMARSHAL@QUEENSBURY.NET
FIRE MARSHAL MIKE PALMER DEPUTY FIRE MARSHAL GARY STILLMAN
Certificate of Occupancy Only Revised December 2020
EMERGENCY CONTACT UPDATE
Please print clearly
DATE: 4/13/21
BUSINESS NAME: The Mohican of Lake George
BUSINESS ADDRESS: 1545 State Route 9, Lake George NY 12845
BUSINESS PHONE: (518)=792-0474
PHONE 1: (518)232-2501
CONTACT 1: Chad Nims
2: PHONE 2:
TOWN/VILLAGE RESPONDING FROM:' Queensbury, NY
PHONE 1: (518)932-9569
CONTACT 2: Pat Jones PHONE 2:
TOWN/VILLAGE RESPONDING FROM: Glens Falls, NY
This form is used to assist Emergency Service personnel who may be called to
your business after hours. Please be sure that the persons listed on this form will
be willing and available to respond during off-hours to assist Police and/or Fire
personnel in gaining entry to your building.
PLEASE BE ADVISED THAT FAILURE TO RESPOND TO ASSIST EMERGENCY SERVICE.
PERSONNEL MAY RESULT IN DAMAGE TO YOUR BUILDING TO FACILITATE ENTRY BY
POLICE AND/OR FIRE PERSONNEL.
TOWN OF QUEENSBURY FIRE MARSHAL'S OFFICE
Phone: 518-761-8206 -* Fax. 518-745-4437
flremarshal@queensbury.net - www.queensbury.net
Fire Marshal Michael J Palmer Deputy Fire Marshal GaryX Stillman
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
• A licant: Wilms
Name(s) N�^^�
Mailing Address, C/S/Z: w—w 54-4,- Cr�l� 1C , UXA..- Geo-or. 44 lZ8%kS
sd--2.32 2�1
Cell Phone: Land Liner
Email: C'n`r,se n cL,s5''�rvl(,�_(7aro.
• Business Owners :
Contact Name(s):
Mailing Address, C/S/Z: iSwcQ S},,\-,- CtcoSat �Pke, F�s� Clic44 W jzg72
Cell Phone: Lanl) Line:
Email:
• Manager:
Contact Name(s):
Mailing Address, C/S/Z: is'-k5 s6-LA-- w 1_4ki Cne-,vg%, W1 tZ:3`4S
Cell Phone: Land Line:
Email: v��5�h��s
• Property Owner(s):
Business Name:
Contact Name(s): C cJ
Mailing Address, C/S/Z: i 5-VS Sk.k ��.1� l_w Ca zd� 2�"�S
Cell Phone: Land Line:
Email:
Contact Person for Compliance in regards to this project: &U k
Cell Phone: Land Line: 5[g-7,37.- 7-56
Email:
Certificate of occupancy Only Revised December 2020