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, `/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: COL, ?ry w,'� Title:. Zip iv Date Sent:
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The Adirondack Park Agency is hereby notified of the receipt of a variance referral record.
Applicant(s): 1-4A&Wfo 4— 01r iJ—h ear Par. Application #: AU
Parcel(s) -_2 27, / 4 - / - 6 rl (tax map #)
For. [Area Variance
Local Zoniniz District(s):
The variance involves (check all that apply):
❑ Use Variance ❑ Septic Variance
APA Land Use Area(s): ❑ Unknown
❑ Hamlet ❑ Moderate Intensity Use ❑ Low Intensity Use
❑ Rural Use ❑ Resource Management ❑ Industrial Use
Shoreline Setback ❑ Density I"Front/Rear/Side/Road Setbacks
❑ Shoreline Lot Width ❑ Lot Size ❑ Road Frontage
❑ Dock/Boathouse ❑ Structure Height ❑ Maximum Lot Coverage
❑ -Other Shoreline Requirements Q'Other: i j, 4/ `�- 5ejiza'c�=5
The attached correspondence contains:
❑ Notice of Application ❑ Application Materials ❑ Meeting Minutes
❑ Record of Decision / Decision Date:
C/Postponed/Tabled (until: 11' RyL()
❑ Granted ❑ Denied
Denied variances do not need to
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