APA Referral AV 18-2022 (Mann) 5.25.22Town. 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, `/o Local Government Services, PO Box 99, Ray Brook, NY 12977
or fax to: (518) 891-3938 or email* to: LocalGovernment@apa.ny.gov
From: 6-elu'Gi o i'o 4l-�,'t Title: Z-0n,rk- Chest rater Date Sent.
The Adirondack Park A1=ency is hereby notified of the receipt of a variance referral record.
Applicant(s): Pan Application #: 4V
Parcels) (tax map #)
For. 03'Area Variance
Local Zoninz District(s):
The variance involves (check all that apply):
❑ Shoreline Setback
❑ Shoreline Lot Width
❑ Dock/Boathouse
❑ Use Variance ❑ Septic Variance
APA Land Use Area(s) : ❑ Unknown
❑ Hamlet ❑ Moderate Intensity Use ❑ Low Intensity Use
❑ Rural Use ❑ Resource Management ❑ Industrial Use
❑ Density
❑ Lot Size
❑ Structure Height
❑ Front/Rear/Side/Road Setbacks
2"'Road Frontage
❑ Maximum Lot Coverage
❑ - Other Shoreline Requirements RrOther: f- Zf' CJI-4f-f, -
The attached correspondence contains:
[�lotice of Application C"Application Materials C"Meeting Minutes
❑ Record of Decision / Decision Date: ❑ Granted ❑ Denied
Denied variances do not need to
BPostponed/Tabled (until: _ / /�`7 3 ) be referred to the Agency
Thank you for your assistance in helping to keep the variance decision record complete.
ForAzency Use:
Log #: LV
Cross References:
Agency Date Stamp — Received:
*Note referrals submitted via email may require follow-up with paper copies. Revised: 8/2017