CO-0503-2021 CERn I - 1v(;CMdjM1 LY office use oniv
- - Permitm (:CJ
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Tom of,Quccnsbuq Permit Fee:--$ I I D• G
8o9t 742 Bay Road,CQueensbury;IV :12 WN OF QUEENSBURY Invoice k :3�20
- BUILDIN, C D-S
P:5187,761-8206.or 518.:MwB_ tteens e
*"Thin application is for occupancy only,,wifh no work requiring a building:pe:rmit*'�`
.BUSINESS INFORMATION: F;D
C E 0 WE
Name of business: Premium Brah s OPCO LLC DBA Loft-.Outle #::1 84
2 21
8,usiness A"ddress:(including suite,-space;.etc):; JUL 0
_ TOWN OF QUEENSBURY
1415.State;Rouie,9. Space41'30"Lake George, NY12845 BUILDING& CODES
Detailed,exp!anation of business (attach a separate piece of paper;if:necessary):
Women's clothing;store:
***Please provide an accurate layout.of.your space showing
all walls_;_ exits,stockrooms, rest rooms,:counters.and fixtures
on.,a separate sheet-of'paper***
IMP.ORANT:-The.business_owner is-responsible for keeping..exits clear and"mainta'ining exit
signs,and.emergency lights: Fire extinguishers;fire sprinkler systems;.and'fire alarm systems
require,annua_ inspections."by an outside contractor and the correspo -di-- documentation
must be prb"vided.toth:e Town of Queensbury Fire MarshaI's office. r re ektinguishingsystems
found.in kitchens and gas stations;require semi-'annual inspections...Any violations noted
during-,an inspection require immediate-correctiive:action and'a re-inspection:
Applicant.name' Tracey
Applicant signature: . Date::. 0512112021
Property Owner name:
Property Owner signature: ,P:/ -Date.:.
'Certificate oi:occupanw Only Revised December 1020
Toiim of Z�sburj
442 Bay Road.,Queens-6 ,NYC 11804
N 518-761-8206 or 518=761-8205 www.gueensbury.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.BUILD1NG:**
PLEASE BE ADVISED THAT FAILURE TO ASSIST..WeRGENCTS.ERVICE PERSONNEL MAY.RESULT IN
DAMAGE TO"YOUR BUILDING BY POLICE AND/OR,FIRE-PERSONNEL.
Date: 05/27/2021
Business Name:
PremiUrri:Brands Opco LLC(LOFT Outlet Store#3084)
Business Location(including suite;space,etc.):
1415 State Route 9 Space 1$0 Lake George;NY'12845
Business Phone#
1. Business contact name: L 44ren Sadii_e.
Main Phone: ;;Secondary" Phone: 598-955=1903
Eoming from what:town/village?-
2. ':Business contact name: Elsha MGlellan
Main Phone: ;Secondary Phone:
'518-223-4249
Co"'niing'froin;what town/village?
TOWN OF QUEENSBURY FIRE MARSHAL'S-OFFICE I
�0: 518-761-8206 F.-51.8-746-4437
FIREMARSHAL@QUEENSBURY.NET
FIRE MARSHAL M[KE PALMER DEPUTY FIRE MARSHAC.GARY S'rILLMAN; j
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certifiete of Occu0anci-6nly Revised December 2020
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