APA Referral 1.26.22 Town of Queensbury - Variance Referral to APA
Agency-approved Local Land Use Program Referral
Please use this form as a cover sheet for any correspondence associated with a variance referral to the
Adirondack Park Agency as provided for in the Town's Agency-approved Local Land Use Program.
Send this cover sheet& variance referral record to:
Adirondack Park Agency, V.Local Government Services,PO Box 99,Ray Brook,NY 12977
or fax to: (518) 891-3938 or email*to: LocalGovernment@apa.ny.gov
From: Gr't u r o�n __ Title:. 7oli i 1$,4m iA,,9"r Date Sent.
The Adirondack Park Agency is hereby notified of the receipt of a variance referral record.
Applicant(s): Var.Application #: Ay 4�aa
Parcel(s) o?.3q (tax map#)
For: ❑Area Variance ❑Use Variance ❑ Septic Variance
Local Zoning District(s): APA Land Use Area(s): ❑ Unknown
❑ Hamlet El Moderate Intensity Use El Low Intensity Use
Pie- J T� ❑ Rural Use ❑ Resource Management ❑ Industrial Use
The variance involves (check all that apply):
❑ Shoreline Setback ❑ Density R Front/Rear/Side/Road Setbacks
❑ Shoreline Lot Width ❑ Lot Size ❑ Road Frontage
❑ Dock/Boathouse ❑ Structure Height ❑ Maximum Lot Coverage
❑-Other Shoreline Requirements ❑ Other:
The attached correspondence contains:
1B Notice of Application ® Application Materials RI'Meeting Minutes
® Record of Decision/Decision Date: eGranted ❑Denied
Denied variances do not need to
❑ Postponed/Tabled(until: ) he referred to the Agency
Thank you for your assistance in helping to keep the variance decision record complete.
For Agency Use: Agency Date Stamp—Received:
Log#: LV
Cross References:
*Note referrals submitted via email may require follow-up with paper copies. Revised:8/2017