LGPC App. 11
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APPLICATION
''" A O PERMIT R 'wf WHARFS
. MIF' AND
MOORINGS
THIS APPLICATION IS FOR
apply)
Constructionof Dock or ($,200) Placement of a Mooring » '
E Modification to an Existing Docko1 M Modification to an Existing Mooring $ A
removal,CffArticle 15 (Repair, aqlacement or installation of cribbingpart of qr •
APPLICATION FEE ENCLOSED: _(check or money order only)
1. OWNER MMI rvAN 0Ms. AAI D' W1NDIVIDUAL PARTNERSHIP
MMW
� ASSOCIATION
LM CORPORATION
wMOw # ' MUNICIPALITY
y
MAJLINGADORESS'
NAME
COMPANY
— ---—--------------------------
MAJUNG ADDPHONE
if ,,,is is an association or if other parties have deeded or contractual access to this lakefront, please complete Addendum A
M
3. CONTRACTOR MI
COMPANY
PHONE
AMCT LOCATION
TOWN 0 T=NDEROGADRESD
�M
0�e(E GEORGE
0 PUTNAI STIR ET
Ul
.LAKE FRONTAGE M AggM . q "qAM
A« ro MMA!"
5. PROJECT DESCRIPTION
M n�
M)4*19
,3POSED USE it RESIDENTIAL COMMERCIAL 0 ASSOCIATION i3 PUBLIC
(PE OF CONSTRUCTION YSTAKE 640RIB 0 PILE ®ARTICULATING 0 OTHER
0 CANOPI I ED SOATLIFT 0 UN-CANOPIED PIE dATLI T C3 PWC LIFT
PROPOSED STARTING DATE PROPOSED COMPLETION DATE A
IS ANY PORTION OF THIS ACTIVITY FOR WHICH A PERMIT IS SOUGHT MVO°lrN'BEGUN OR COMPLETED?
Year i "ko (D yes,please explain)
IF COMMERCIAL,IS TIME FACILITY AND ITS ASSOCIATED LA140 USES IN COMPLIANCE WITH APPLICABLE.
P;RPVISIONS OF STATE AND LOCAL LAWS, ORDINANCES,RULES AMICI REGULATIONS?
Yes 0 No(Mf no, please explain)
6. ADJOINING LAKEFRONT PROPERTY OWNERS (avaliable from your town or county real property dept.)
NAME NAME
TAX I' AP � � -0 TAX
MAILING e. MAILING
ADDRESS b9-jl7a d/- ADDRESS
1�11-014,72
". CERTIFICATION
I hereby affirm that the informatdn on this form and all attachments submitted herewith is true to the best of my
knowledge and belief"
I hereby consent to the Commission staff working directly with my agent„ as designated on page 1 of this form„ during
the review of this application.
Curing the processing of this application Lake George Park Commission (LGP ;) personnel or their assigns may need
to visit this site to inspect, measure, snake drawings and/or take photographs. I hereby agree that LC PC staff or their
assigns may enter upon and pass through this properly in order to inspect the project site or facility" Mthout prior
notice, between the hours of :00 a.m. and :00 p.m., Monday through Friday"while the application is pending. In the
even: that the project site or facility is posted with any faun of"posted"or"keep out" notices„ or fenced in with an
unlocked gate, this permission authorizes LGPCy staff or their assigns to disregard such, notices or unlocked gates at
the time of inspection.
As a condition to the issuance of a permit„ the applicant accepts fvIl legal responsibility for all damage, direct and
indirect, or whatever nature, and by whomever.suffered, arising out of the project described herein and agrees to
irdemnify and save harmless the ;Mate from suits, actions, damages and costs of every name and description
resulting from the said project.
SIGNATURE OF OWNER (dote itle if signing fo /d corporation or association) DATE
PL SE COMPLETE ALL 11 EMS ABOVE AND INCLUDE WITH THIS FORM:
i
0 Application fee
Site location reap
l 0 Copy of survey If available
0 Project plains on 8 IA X 11 size paper -PLANS MUST BE TO SCALE & SHOW ENTIRE LAKEFRONT
u lC Short Environmental Assessment Form if project involves
"
A new Association or Commercial dock or mooring
0 More than one residential dock:or mooring
i A doctor our mooring to be located in a wetland,fish spawning area, an ,area of significant
wildlife habitat, or an area of unique .scenic, historic or natural significance
Ll Addendum A Co-owner Signature Page (If lakefront is jointly or commonly owned)
D Addendum B Parties with deeded or contractual access to this lakefront
Failure to tractudo any one of the regutrad tte ms MY result in art Incomptate notice and dolay to processing your appticadon. Permits
and ampvsmayrequired ranaocles and municipalities
r
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