CO-0716-2022 DocuSign Envelope ID:236C6F3B-74F3-46E5-8B6F-C298ACB9E9EA
c RT1-FICA t OF OCCUPANCY ONLY office use:or y
Permit
APPLICATION
9rnim a7F2e�washui Pe'rnit_Fee,:$ --
Invoice#:
742 Bay Road,;Queenspury;NY 12804
P:518=761-8206 or 518-761-M05: WWW.gUeensbury.net
*This application-Irs for occupancy only, with. no work requiring a:b.uilding=permifi**
BUSINESS INFORMATION:
Name of business; . . L -
BusinessAd.dress (Inc
luding.suite; space, etc:): lr�_ ; t�r� �G�j�tre�ns iU _:
� �a�r q
Detailed-explanation of business.(attach a.separate piece of paper.,if necessary):
\ 2r (A A . A-rA :k:V
Please. � roMO an Aecwarte layout of°your_. :_ : -
.. _ ,"win p _pass.s6o .. g
"
l[ waUs, ;eats,,::stocla�oo�ns, rest: rooms, counftts_and rnctzw
a separate-sheet of paper
-IMPORANT: The business_owner is:responsibl'e for keeping-exits clear and maintain,*ng,e'x t,
signs and emergency lights.. Fire extinguishers, fire sprinkler systems; and fire,-.aaarm.syste S .
require annual inspections;by an.outs'ide contractor and the correspgnding:Aocumentation .:
must be provided`tq'the�Town of'Queensbu'ry Fire Marshal's office:: Fire extinguithing.systems:
found.in kitchens.and,,gas stations- require semiannual inspections:. Any ,violations noted
. durinl .an inspectionrequire immediate.corrective-action and'a-re=inspection. . .
Applicant name:
Applicant signature.: Date: I. ao
Christopher Falvey
Property Owner nam:e: . _: . . .
- OocuSigneH hy:. -
Dec-01-
Pro.perty. OWner.sig_nature ate: -°- . . . .
CA48F742819148A., - -
LULL
TOWN OF QUEENSBURY
BUILDING&CODES
C&6k.64Occupaney Only Revised`5eptember.2022
DocuSign Envelope ID:236C6F3B-74F3-46E5-8B6F-C298ACB9E9EA
Teitin`uf Qucrnsbun'
Al Bay:Road;QUeensbUry,NY 12804
P SiS-761-8206 or.51&761-8205' www.aueensbury.net
CONTACT INFORMATION.:Rl EASE'PRINT LEGIBLY OR TYPE; P.LEASUNCLUDE AN.EMAIL
! Applicant:
Mailing Addr . s; C/S/Z: rii ..
A
-CellePhone: .-- . ) - Land Line. fi)
Ernail: C�i'�rF, hf�r C��•
• Businesg Owner(s)::
_Contact lVame(s):.�Vi�.��IP ����. _G��r��; VQli�i
Mailing Address;.C/S/Z:.
Cell'Phone: _ �`6_.,. ): jt W 77. 2 Land Line:
Email:- .i1` � k .'C'0"
• Manager; 1
Contact Names ; � '
Mailing Ad'dr..ess,-.C/S/Z:. _
Gell;Phone:_l ) Land Line:
Email: _ 7 ze1ri C. . G d
Property Owner(s): -
---..
Business Name:. uw S.
Contact Na-me(5 Gl -. .
Mailing.Address;
Cell Phone:
Email:
:Contact-Person for Compliance in regardsto this project: W
CeII.Ph(jne: .( b fzf .) 00-230c, Land Lines- N Fmr) -
Email' :
c."G,Ca: of dccoaney'01v Revised sepf6ii ber2022
DocuSign Envelope ID:236C6F3B-74F3-46E5-8B6F-C298ACB9E9EA
Totrn uCrcensbuiy
742 Bay Road;,Queensbury,NY 12804
0:5187-161-9206 or.5Sg-761-8265 . .,www.queensbury.net
Eli' ERGENCTCONTACT.INFORMATIO.N
*THIS FORM IS-USED TQ ASSIST EMERGENCY SERVICE:PERSONNEL W,HO;IVIAY BE-CALLED'TO YOU_R'-
BUSINESS AFTER HOURS ..PLEASE BE.SURETHE CONTACTS LISTED_BELOW ARE WILLING AND
AVAILABLE:1 O RERSOND DURINGQFF=HQURS TO ASSIST PQ-LICE AND%O;R FIRE PER.$ -NEL:IN
GAINING ENTRYTO.YOUR BUILDING:**
PLEASE:BE'ADVISED THAT.FAILURE;;TO ASSIST EMERGENCY SERVICE.-PERSONNEL,MAY LTK _
DAIV(AGE_TO YOUR,BUILDING t3Y-FOLICE AND/OR`FIRE'PERSONNEL:
BusinesnName:. 1 rLlU..
Business:;Location'(i,ncluding suite,space,-etc.):_ -�'` uj\QIf
`P
.Busin'ess Phone# 01 "1 O "` �- o
1. Businesslcontact name:: lU� �- 1co
.` �J
C, r r. . . . . . . . . . - . -
Main.Phone:_(. ) b - Ziy�secondar Phone:_
Contact is coming from.what— -town/village? -S"CA�nCA
2.. Business contact name:. . .
Main.P.h'�one:_(.... . - ).. -----_ ;Secondary Phone:
Contact incoming from what town/village?
TOWN OF.QUEENSBU.RY FIRE MARSHAL'S OFFICE.
P:51&76.1-8206 F:518-745-4437
FIREMARSHAL@QUEENSB URY:NET
FIRE MARSHAL.NIIKE.PALMER DEPUTY FIREMARSHAL TYSON CONVERSE
certificate of Occupancy only R4%ilM SeptdMber 2022
THE INSPECTOR CO- 0r'rl I-,—- 20 22-
5390 State Route 11,Burke,NY 12917
1-800487-0535 www.theelectricalinspector.com
Date:November 28,2022 Application No.On File:172551
THIS CERTIFIES THAT Fowler Square With Grace MHC
Only the electrical equipment as described below and introduced by the applicant named on the above application number in the premises of: r
791 Bay Road Town of Queensbury Contractor: A.E.Rosen Electric
In the following location: Basement I'Floor X 2nd Floor No.of Apt Garage Attic Outside Commercial X Residence
Was examined on 11/22/22 and found to be in com fiance with the requirements of the National Electric Code.
GFCI Fixture Outlets Receptacles Switches Fixtures Ran es Cookin 4 Decks Ovens Dish Washers Exhaust Fans Smoke/Heat
Incandescent Fluorescent Other Amt K.W. Amt. K-W. Amt. I K.W. Amt. K.W_ Amt. K.W. Detectors
3 74 38 13 74 1 FR
LED
Dryers Furnace Motors Dimmers Water Heaters Unit Heaters Multi Outlet Sys. Electric Heaters
Amt. K.W. Oil H.P. Gas H.P. Amt. I Watt Electric Oil Gas Amt. Rating No.of Feet Amt. K.w. I Amt. K.W. I Amt. ICW. Amt. K.W.
I
Transformers Alarm Systems Special Rece tacle Panels Motors Signs Track Lighting Dis osal
Amt. KVA A/V PS Det. Panel Amt. K.W_ Amt. No.of circuits Rating Amt. H.P. Amt. No_of Lams No.of Heads Amt. H.P.
1 2 20
1 20 150
Service Disconnect Equipment Service
Amt. Amp- I Type Meter 1 Phase 1 Phase 3 Phase 3 Phase I No.of CC. AWG. No.of AWG.of No.of AWG of
2W 3W 3W 4W Cond./phase CC.cond. Neutrals Neutrals HI-Les HI-Legs
Other Apparatus
3 Emergency
2 ExittEmergency
Manager
This certificate must not be altered in any manner;return to the office of THE INSPECTOR if incorrect. Inspector's credentials can be verified.
t - -
289.19-1-27 CO-0716-2022
With Grace MHC
719 Bay Rd, Suite 2101
Certificate of Occupancy
IX
i- LARGE OFFICE LARGE OFFICE
E t 163 SF t'180 SF FFICE
t :130 SF
OFFICE
ENTRY=- t,2p SF
PATIENT X
TOILET
REAK ROOM/
ONFEREN]E OFFICE OFFICE OFFICE
2W S t 130 SF t 130 SF t 130 SF ELETRICAL
jAlt
WAITING i p
R.
{� S P iL/IvK,�W4-
AS-
R�SETTI "' GRACE'MHC=TENANT SPACE PLAN BBLCkmsftwftf
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FOWLER FOWLERSOUARE Sole Ire'=,
Q clijiacis - �_ VICES PROPERTIES• n se 719 SAY ROAD,QUEENSBURYI NY 0T262022'
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