APA ReferralTown 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
From: ✓ ruc Title:. Zan f' f} nch FSfi+�iw Date Sent: �rlaeiloq
The Adirondack Park Agency is hereby notified of the receipt of a variance referral record.
Applicant(s): ketie,�-i ern Par. Application #: AV 36 -�a�
Parcel(s)! (tax map #)
For: fErArea Variance
Local Zoning District(s):
W r\
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 V Front/Rear/Side/Road Setbacks
❑ Shoreline Lot Width ❑ Lot Size ❑ Road Frontage
❑ Dock/Boathouse ❑ Structure Height ❑ Maximum Lot Coverage
fi0/Other Shoreline Requirements P Other: rA, a ;- Ari(e ,t- PermeoJvi f%
The attached correspondence contains:
ErNotice of Application ETApplication Materials 2"Meeting Minutes
❑ Record of Decision / Decision Date: ❑ Granted ❑ Denied
Denied variances do not need to
CdrPostponed/Tabled (until: 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