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FWW PermitUpdated: 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. * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * 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. ___________________________________________________________________ ___________________________________________________________________ Paul Nasrani 210 East Broadway, #H601 NY,NY 10002 917-287-1006 USACE Freshwater Wetland 790 Bay Road, Queensbury, NY 12804 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. Purpose, character and extent of proposed activity upon or adjacent to wetland: ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ 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? ______________________________ 289.15-1-47 Moderate Density Residential 6.48 acres 0.33 +/- 13,746 sq. ft. NA Residential, Municipal Town of Queensburyproperty Three lot subdivision within Moderate Density Residential. Existing single family lot to remain. Two new residential lots proposed. Proposed activity adjacent to the wetlands includes the construction of an access driveway for new lots 2 and 3. No wetland disturbance proposed. Yes No 2023 2023 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: __________________________________________________________________________ __________________________________________________________________________ _______________________________________________________________________ * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * 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. H. Thomas Jarrett, P.E. Robert Bombard, Allison Friers, Brian Byrnes, Anthony Ryan Grace,Jesse Bashant, William Howe, Surrey Field Homeowners Assoc, Evelyn McPhee, Richard Wright Town of Queensbury, Halcyon Properties. Nancy Hillis United States Army Corps of Engineers