APA Referral (To TABLE) 1.19.22 Town 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, `/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: CTl-C Gf �j c J/l Title: p i,�fi ,�,k,,}y�rDate Sent: L31
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The Adirondack Park Agency is hereby notified of the receipt of a variance referral record.
Applicant(s): 6r Y 6c;5 4-- Pan Application #: AV '7�C-tea 1
Parcel(s) (tax map#)
For. 0 Area Variance ❑ Use Variance ❑ Septic Variance
Local Zoning District(s): APA Land Use Area(s): ❑ Unknown
\ ❑ Hamlet ❑ Moderate Intensity Use ❑ Low Intensity Use
(fV ❑ Rural Use ❑Resource Management ❑ Industrial Use
The variance involves (check all that apply):
® Shoreline Setback ❑ Density ® Front/Rear/Side/Road Setbacks
❑ Shoreline Lot Width ❑ Lot Size ❑ Road Frontage
❑ Dock/Boathouse ❑ Structure Height ❑ Maximum Lot Coverage
❑-Other Shoreline Requirements 0 Other:-F(oo,-Arw,
The attached correspondence contains:
9 Notice of Application 11 Application Materials Meeting Minutes
❑ Record of Decision/Decision Date: ❑ Granted ❑Denied
Denied variances do not need to
Postponed/Tabled(until: c2 /& /a o; ) be referred to the Agency
Thank you for your assistance in helping to keep the variance decision record complete.
For Agency Use: Agency Date Stamp—Received:
Log#: LV
Cross References:
*Note referrals submitted via email may require follow-up with paper copies. Revised:8/2017