APA Referral AV 20-2022 (Carlson) 7.20.22Town. 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'sAgency-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: LocalGovernmentpapa.ny.gov
From: G, ; v cj_-� i-1 Titte:i r1 i� t Date ,Sent:
The Adirondack Park Agency is hereby notified of the receipt of a variance referral record.
Applicant(s): t L .- i5 Far. Application #:_A-V a3 -'p_>;a
Parcel(s) 02---3q. 1 a - a`Z (tax map #)
For. Ld"Area Variance ❑ Use Variance ❑ Septic Variance
Local Zoning District(s):
�v
The variance involves (check all that apply):
Shoreline Setback
❑ Shoreline Lot Width
APA Land Use Area(s): ❑ Unknown
❑ Hamlet ❑ Moderate Intensity Use ❑ Low Intensity Use
❑ Rural Use ❑ Resource Management ❑ Industrial Use
1-0 e ❑ Density
CSCv,,e
❑ Lot Size
❑ Dock/Boathouse ❑ Structure Height
❑ - Other Shoreline Requirements ❑ Other:
The attached correspondence contains:
Setbacks
❑ Road Frontage
❑ Maximum Lot Coverage
❑-'Notice of Application laAApplication Materials la Meeting Minutes
❑ Record of Decision / Decision Date:
@`Postponed/Tabled (until: ")19/ I ,? 9 )
❑ Granted ❑ Denied
Denied variances do not need to
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