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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, V. Local Government Services, PO Box 99, Ray Brook, NY 12977 or fax to: (518) 891-3938 or email* to: LocalGovernment@apa.ny.gov From: Date Sent: The Adirondack Park ALrency is hereby notified of the receipt of a variance referral record. Applicant(s): etjt!�n fa n Var. Application #: AV '7-_�)- � Parcel(s)'75,-'7 (tax map #) For: ©'Area Variance Local Zoning District(s): Ki' :3 i 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 ❑ Shoreline Lot Width ❑ Lot Size ❑ Dock/Boathouse ❑ Structure Height ❑ Other Shoreline Requirements ❑ Other: The attached correspondence contains: Front/Rear/Side/Road Setbacks ❑ Road Frontage ❑ Maximum Lot Coverage C'Notice of Application 2"'Application Materials 2'Meeting Minutes fi�' Record of Decision / Decision Date: / t2 / 8 lcX-t 2 Granted ❑ Denied Denied variances do not need to ❑ Postponed/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