APATown 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, e/o Local Government Services, PO Box 99, Ray Brook, NY 12977
or fax to: (518) 891-3938 or email* to: LocalGovernment@apa.ny.gov
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From: �V ��t Ct�'oc z�%'� Title: Sent: 3 v3
The Adirondack Park Agency its hereby notified of the receipt of a variance referral record.
�. Applicant(s): ka'—O/q '5e-"y11Par. Application#: A1/
Parcel(s) O?q Q" q - / —g( (tax map #)
For. ®Area Variance
Local Zoninff 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
C'Structure Height
❑ - Other Shoreline Requirements EYOther: f;'lvt>,- A-reor
The attached correspondence contains:
Setbacks
❑ Road Frontage
❑ Maximum Lot Coverage
❑ Notice of Application ❑ Application Materials ®'Meeting Minutes
❑ Record of Decision / Decision Date: ❑ Granted ❑ Denied
Denied variances do not need to
02/Postponed/Tabled (until: 111U(/ be referred to the Agency
Thank you for your assistance in helping to keep the.variance decision record complete.
For Agency Use:
Log #: LV
Cross References:
Agency Date Stamp — Received:
*Note referrals submitted via email may require follow-up with paper copies. Revised: 8/2017