application E C E W E
ICA OCCUPANCY ONLY office use Only
;1UL 01 2021 Permit M., C)
P. ICATION
T°" 'of,(+ `l�ii�`OF C1U Ei\1SBl)RY Permit Fee:$ (1 1,. U C�
t_Llii•fG Rx CQ®ES invoice
742 a Rons6uriy�N ,1804°
P:51&761=8206 or 51&761-8205 ;itiudrv.064eMdurV:net
**This a lication is:for pecu .anc onl` with no work requiring a building permit*
pp . p . . Y. Y.
-
9USINESS'1NFORMATION:
Name of business: Lane Bryant Brands OP.CO,LLC;DBA Lane Bryant 4:120
Business,Address (including suite;space, etc,
):
1.424 STATE ROUTE 01T!�SPACE:#4.
Lake George,NY 12845
Detailed explanation of pusine'ss:(attach a separate piece`,of papet; if n.ecessary);-
""Pleate provide an accurate JoVyOot:of your sNaCeshOWing
all walls, exits,:stockrooms,rest rooms.'counters and fixtures
on a separate sheet,of paper***
IMPORANT:The business owner is responsible for_keepingexits_clearand ma'intai.riing exit
signs and.emergeruy-lights,: Fire extinguishers,'fire spnnKler systems; and fire alarm:systems
re"quire,annual inspections by!awoutside contractor and the corresponding:documentation
must be provided to the Town.of Queens bury Fite Marshal's-:office. Fire:extinguishing systems R
found)in kitchens and ga§:stations-...'e.ggj semi-annual,inspections.. Any.violations noted
during.an'inspection require immediate:corrective action--and,a re=inspection:
7
Applicant name;Tracey.S r'man
r `
Applicant signature:.. Date-Date; "05127[2021 !
Property-.Owner n:arne:
Property Owner signature:'- /.�
Certificate-of occupan-CY
jb* Revised December.2620
D
E c E 0 w
JUL 01 -1021
9
TOWN OF QUEENSBURY
Foiin,'ofChw6sbury BUILDING F?s CODES
742 Bay Road,aueensbury,AY'12864
P:;518=7611206'0 518-761-8265, iivuv%4mL eensburv:net
EMERGENCY CONTACT INFORMATION
*THIS:FORM IS USED.TO-ASSIST EMERGENCY.SERVICE_PERSONNEL WHO MAY BE CALLED TOYOUR
BUSINESS.AFTER HOURS,PLEASE:BE SURE THE CONTACTS';LISTED BELOW ARE WILLING.AND'
AVAItABLETO,.REPSOND DURING OFF-HOURS TO ASSIST POLICE AN D/001 RE-PERSONNEL IN.
GAINING ENTRI(Tb YOl1R BU.ILQIiVG**
PLEASE BE ADVISEDTHAT FAILURE TO ASSIST EMERGENCY SERVICE PERSONNEL MAY RESULT IN
DAMAGE TO YOUR-BUILDING BY POLICE AND/OR FIRE PERSONNEL..
Date:. 05/27/2021
Business Name:, Lane'_W a6 it#.421'0
Business Location(including sulte,.space;;etc:): The.O'utlets at Lake George
1421 State Route 9,8pace.,4 .
Lake George,NY 12845,
Business Phone 9-
1. Business contact;name.: Kelly Nichols
Main Phone:° ;Secondary Phone: 518,812-9506
Coming from what.:toWn/village?
2. Business contact.name Courtney Hartwell
Main Phone: Secondary Phone: '518-466-4883
Coming-from whet town%village?
TOWN OF QUEENSBURY:FIRE MARSk1AL'S,OFFICE
R-518-761-8206 F:5`t 8-745=4437
FI F2EMARSH,4L@ OU@ElVS6 G'F2Y.N ET':
FIRE MARSHAL MIKE,PALMER DEPUTY FIRE MARSHAL GARY STILLMAN
Certificate o(Occupancy Only Revised Deceinber 2020