Freshwater Wetlands Permit ApplicationUpdated: 03/05/2004
TOWN OF QUEENSBURY
FRESHWATER WETLANDS PERMIT APPLICATION
APPLICATION NO.: _______________
APPLICATION DATE: _______________
This is an Application for a Permit to conduct/cause to conduct a regulated activity on or
adjacent to a freshwater wetland pursuant to Freshwater Wetlands Protection Law - Local
Law 1, 1976.
TO: Town Clerk of the Town of Queensbury - Please immediately forward this
application to the Planning Board of the Town of Queensbury by way of service upon the
Planning Department of the Town of Queensbury.
TO: Applicant - Please type or print the information required and complete all blanks and
answer all questions. If the information requested is not applicable, please enter N/A. Please
provide the original plus 14 copies of this application with a $100 application fee.
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INFORMATION FOR APPLICATION
Applicant:
Name: ______________________________
Address:______________________________
______________________________
Phone: _______________
Property Information:
1. Name of wetland or any body of water/stream involved:
2. Address of parcel upon which wetland is located and address of parcel(s) upon which
work is proposed.
___________________________________________________________________
___________________________________________________________________
The name of the wetland in unk___________________________________________________________________nown.
Updated: 03/05/2004
3. Tax Map No. of parcel upon wetland is located and Tax Map No. of parcel upon
which work is proposed: _____________________________________
4. Current zoning of parcel upon which wetland is located and current zoning of parcel
upon which work is proposed: _________________________
5. Total area of property upon which work is proposed: ___________________
6. Total area of wetland: ____________________
7. Dimensions of wetland: ____________________
8. Existing uses of wetlands, if any:
___________________________________________________________________
9. Adjacent uses within 400 ft. of wetlands, if any: ____________________________
___________________________________________________________________
10. State, County, Town property within 500 ft. of wetland:
___________________________________________________________________
Information About the Project:
1.Detailed description of proposed activity: _________________________________
2.
3.On a map to be 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.
4.Will the project require any other Federal, State or local permits? ______________
___________________________________________________________________
5.Has work begun on the project? ________________________________________
6.Approximate starting date of project? ___________________________________
7.Approximate completion date of project? ______________________________
The wetland is located on Tax Parcel No. 239.7-1-17.The parcel in which work in proposed is Tax Parcel No. 239-1-20.
Both parcels are zoned as Waterfront Residential
Raze the existing seasonal residence with a 1,067 SF
___________________________________________________________________footprint along with the existing +/- 84 SF storage shed and construct a residence with a 2,558 SF footprint (4,091 SF
total). Proposed site improvements include an on-site wastewater treatment system replacement, well replacement,
driveway, stormwater management practices, patio space, outdoor kitchen, and landscaping.
Purpose, character and extent of proposed activ ity upon or adjacent to wetland: _________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Looking at aerial photography, the wetland appears to be undeveloped, however, there are residential uses within 100'
of the wetland boundaries.
The only public property within 500' of the wetland is the right-of-way- for roads. Lake George is also within 500' of
the wetland.
2,100' x 450'(approximately)
Updated: 03/05/2004
About the adjacent property owners:
List the names of the owners of record of lands adjacent to the freshwater wetland or
adjacent area upon which the project is to be undertaken:
__________________________________________________________________________
__________________________________________________________________________
_______________________________________________________________________
Name of claimants of water rights which you have noticed and which relate to any land
within or within 100 ft. of the boundary of the property on which the proposed regulated
activity will be located:
__________________________________________________________________________
__________________________________________________________________________
_______________________________________________________________________
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The foregoing information will be reviewed by the agency, and the agency, may if it desires,
request any further information necessary to make a decision.
I hereby affirm under penalty of perjury that the information provided herein and all
attachments submitted herewith are true to the best of my knowledge and belief.
Signature: ___________________________________
I hereby authorize ______________________________ to act as my agent and represent me
in connection with this application on my behalf.
See signed Agent Authorization Form in Site Plan Review Application and Area variance Application
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LIMITS OF DISTURBANCEAPA WETLANDAPA WETLANDCivitella ResidenceQUEENSBURY, NYP 518 450 4030 · STUDIOADPC.COM38 HIGH ROCK AVE SUITE 3 · SARATOGA SPRINGS NY · 1286612.15.2021 · SA PROJECT NO. 20058Wetland MapGRAPHIC SCALE204001 inch = 40 feet10