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21004 230502 Wtlnd Appl sgndUpdated: 03/05/2004 TOWN OF QUEENSBURY FRESHWATER WETLANDS PERMIT APPLICATION APPLICATION NO.: _______________ APPLICATION DATE: _______________ This is an Application for a Permit to conduct/cause to conduct a regulated activity on or adjacent to a freshwater wetland pursuant to Freshwater Wetlands Protection Law - Local Law 1, 1976. TO: Town Clerk of the Town of Queensbury - Please immediately forward this application to the Planning Board of the Town of Queensbury by way of service upon the Planning Department of the Town of Queensbury. TO: Applicant - Please type or print the information required and complete all blanks and answer all questions. If the information requested is not applicable, please enter N/A. Please provide the original plus 14 copies of this application with a $100 application fee. * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * INFORMATION FOR APPLICATION Applicant: Name: ______________________________ Address:______________________________ ______________________________ Phone: _______________ Property Information: 1. Name of wetland or any body of water/stream involved: ___________________________________________________________________ 2. Address of parcel upon which wetland is located and address of parcel(s) upon which work is proposed. ___________________________________________________________________ ___________________________________________________________________ Lake George (Warner Bay) The wetland is a part of Lake George in Warner Bay. The work is proposed on parcel 227.14-1-17 Updated: 03/05/2004 3. Tax Map No. of parcel upon wetland is located and Tax Map No. of parcel upon which work is proposed: _____________________________________ 4. Current zoning of parcel upon which wetland is located and current zoning of parcel upon which work is proposed: _________________________ 5. Total area of property upon which work is proposed: ___________________ 6. Total area of wetland: ____________________ 7. Dimensions of wetland: ____________________ 8. Existing uses of wetlands, if any: ___________________________________________________________________ 9. Adjacent uses within 400 ft. of wetlands, if any: ____________________________ ___________________________________________________________________ 10. State, County, Town property within 500 ft. of wetland: ___________________________________________________________________ Information About the Project: 1. Detailed description of proposed activity: _________________________________ ___________________________________________________________________ 2. Purpose, character and extent of proposed activity upon or adjacent to wetland: ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ 3. On a map to be submitted with this application, show the area of the freshwater wetland or adjacent area directly affected with the location of the proposed activity shown to scale thereon as well. 4. Will the project require any other Federal, State or local permits? ______________ ___________________________________________________________________ 5. Has work begun on the project? ________________________________________ 6. Approximate starting date of project? ___________________________________ 7. Approximate completion date of project? ______________________________ NA NA 0Xltiple other residential properties are located within 4 ft. of the wetland. Both 3ilot KnoE Road and 3XlYer Road are within  ft. of the wetland. NA We are proposing a  EedrooP hoXse on a Yacant shorefront lot in Warner Bay on Lake George. The proposed strXctXre lot is adMacent to a wetland. This is the lot.with a proposed residence. A driYeway and residence are all that are Eeing proposed as far as iPperYioXs . An A3A -,) was filed. No other perPits are reTXired Eesides toen of Lake George Site 3lan approYal. No )all 22 )all 224 Updated: 03/05/2004 About the adjacent property owners: List the names of the owners of record of lands adjacent to the freshwater wetland or adjacent area upon which the project is to be undertaken: __________________________________________________________________________ __________________________________________________________________________ _______________________________________________________________________ Name of claimants of water rights which you have noticed and which relate to any land within or within 100 ft. of the boundary of the property on which the proposed regulated activity will be located: __________________________________________________________________________ __________________________________________________________________________ _______________________________________________________________________ * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * The foregoing information will be reviewed by the agency, and the agency, may if it desires, request any further information necessary to make a decision. I hereby affirm under penalty of perjury that the information provided herein and all attachments submitted herewith are true to the best of my knowledge and belief. Signature: ___________________________________ I hereby authorize ______________________________ to act as my agent and represent me in connection with this application on my behalf. 9incent Andretta  0ary La)orte SerEalik )aPily.