Freshwater Wetlands Permit Application 7
Upola eel: 031,0512,004
t,
TOWN OF llJEENSBZJRY
FRESHWATER WE")<'LAND PERMIT APPLICATION
APPLICATION NO,.:
APPLICATION DATE.
This is an Application ftur ai Permit to, conduct/cause to, conduct a regulated ao:tivit on or,
adjacent to a ft sh ° ter wettand pursuant to Fre $water Wetlands Protection,n, a - Local
Law 1,, 1976.
O: Tol n Clerk of the Town of Queensbury _ Please immediately forward this,
application toy the :Planning Pinard of the Town of Queensbury by way of'service upon the
Planning Department ofthe'Iawn of Queeiisbury.
T Applicant - Ply t pe or Print the information required and complete all blanks and
answer all.questions. If the information requested is not applicable,pleas,e enter N/A., Please,
provide the original luus 14 copies ofthi poligation with a 1001applicationfet.
Name:
Address: L2 60K A/V
P,h n -.
Propegy Inform,ation:
1, News ofwetl;and or any body ofu at ulstrearn involved:
Address of parcel uuponl ich wetland is lotted and address ofparee s) upon which
work is proposed.
1 ��� � l' "
.,... — �
Updated: 03/05 2004
. Tax Map No. of parcel. upon wetland is located and Tax Map No. cud"parcel upon
lynch work is Proposed: . I —/— a
4. Current zoningof parcel upon which wetland is located and current zoning ofparcel
upon which word is,proposed: MIC
. Total area of propene upon.which work is prppe ed� 1
.. Total area of wetland.
7., Dimensions of
wetland—
. Existing uses of wetlands,, if any:
. Adjacent uses within 400 ft. of wetlands, if any:
10, State, County,Town property within n fl .ofwetland.
Information Ab u t the Pro'tct:
p., Detailed description of proposed activity: � '���� � r tj'
)
2. Purpose, character and extent of proposed activity a lion or adjacent to wetland:
Ags
1. Our a r nap to he 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.
. Will,the project require ire,arn other Federal, State or lineal permits'
. Has work begun on the project?
. Approximate starting date of project?
. Approximate completion date of project? AJ7 J/ '7 4 I'
Updated: 03/0512004
About the adjacent rug g. owners:
List the names of the owners of record or lands adjacent to, 'the Freshwater wetland oil
adjiacent areaupon which the project is to be undertaken.,
v1Aae
CWOrt--I. --, C—r±lv
Name of claimants of water rights which you have: noticed and which relate to any land
with in or with i n I O0, ft. of the boundary of the propei ty on wh i cb the proposed regu I ated
activity will be located:
PJAY
The: foregoing information will be reviewed by the agency,and the agency, may if it desires,
request any further information ne:cess,ary to make a decision.
ir�,r ation, provided herein and all
I hereby affirm under penalty of perjury that the nfo
attachments,submitted herewith are to the best of m n 'edge and belief
Signature:�
10
I hereby authorize--,O,/4- to act as my agent and represent me
in connection with this application on my behalf