Fillable Printable Jurisdictional Inquiry Form
Fillable Printable Jurisdictional Inquiry Form
Jurisdictional Inquiry Form
JURISDICTIONAL INQUIRY FORM
A. INSTRUCTIONS
Submit this form to obtai n a written determination whether an Ad i r ondack Park Agency
permit or variance is needed for a proposed project. This form is not an application. If
you know you nee d an Agency permit or variance you should not submit this form, but
instead you should contac t the Agency fo r the appropriate application form.
Information about Agency jurisdiction can be found on the Agency’s w ebsite
(www.apa.ny.gov) and in the Permit Checklist on pages 10 and 11 of the Agency’s
‘Citizen Guide,’ which is also available on the website.
The Jurisdictional Inquiry Form must be si gned by owners of land or their attorney, or
by purchasers who have a signed contract of land or their attorney. Please note that if
the person under contract to purchase the property or his attorney signs this form, then
a copy of the purchase agreement signed by both pa r ties must be provided.
The legal issues involved in determining jurisdiction are complicated. All of the
information requested on this form is necessary in order for us to determine if the
proposal requires an Agency permit or variance. The County Clerk's Office, Real
Property Tax Services and/or the Town Office may be able to assist you in obtaining
property information (i.e ., tax map number, history, copies of deeds, etc.).
Please include a copy of the current recorded deed, tax map number, a description of
your proposal, including a sketch map, and the necessary signature(s).
WE CANNOT RESPOND TO YOUR INQUIRY WITHOUT THIS INFORMATION
B. GENERAL INFORMATION
APPLICANT/REPRESENTATIVE: PROPERTY OWNER (if not a ppl icant):
Name ________________________________ ________________________________
Mailing
Address ________________________________ ________________________________
________________________________ ________________________________
Telephone ______________________________ ________________________________
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PROPERTY LOCATION:
Town/Village ________________________ County _____________________________
Road/Highway ____________________________________________________________
Tax Map Number: (This can be found on your tax bill and it looks something like this… 89.12-
1-1.4 - three nu mb er s s eparated by dashes, and ther e may not b e dec i m als ) .
Section ______________ Block ______________ Parcel/Lot ______________
C. PROPERTY HISTORY
Please include a copy of the current recorded de ed for the property.
1. Has the property been the subject of any previous Agency permit, variance, map
amendment, jurisdictional determination, staff s ite visit, wetl and site visit, or an enforcement
action?
☐Yes ☐ No ☐ Don't Know
If yes, please include the following information:
File number ___________________ Agency contact _________________________
2. W hat is the acreage or square footage of the property at this time? ______________
3. Please describe all structures which currently exist on the property (include type and use
of structure, size and construction date of each – for example, confirm if the structure is a
mobile home, single family dwelling, barn, storage building, etc.). If your project involves
replacement of a structure, please provide its descr i pti on , even if it has already been
removed (and indicate its removal date).
Structure/Use Size Construction Date Removal Date
a. ___________________ __________ _______________ ________________
b. ___________________ __________ _______________ ________________
c. ___________________ __________ _______________ ________________
d. ___________________ __________ _______________ ________________
e. ___________________ __________ _______________ ________________
f. ___________________ __________ _______________ ________________
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D. PROJECT DESCRIPTION
Please check all that apply and fill in the appropriate bl anks:
1. ☐ Subdivision
(a) Number of proposed lots (including any lots being retained). _____
(b) W hat is the size of the smallest lot in acres or square fee t? ___ __
(c) What is the smallest shoreline lot width (if applicable)? _____
(d) Are any of the proposed lots being conveyed by gift? ☐Yes ☐ No
If yes, what is the recipient’s rel ati o ns hip t o th e person giving the lot?
_______________________________
☐ Construction of a s ingle f amily dwelling.
☐ Installation of a mobile home.
☐ Construction of a multiple-residence building ( ____ housing units).
☐ Construction of a commercial, industrial or public building resulting in ______ square
feet of building footprin t and ____ ___ square feet of floor space ( t otal of all floors) .
☐ Expansi on o f the footprint of an existing _______ square foot structure by _____
additio nal squar e feet. For group camps and public buildings, please also provide
expansion information for the total of all floor space. NOTE: If you are expanding a
structur e other than a sing l e-family dwelling, also provide the total square footage of
the structure as of May 22, 1973.
☐ Are you proposing to install, replace or expand a seepage pit, drainage field or other
leaching facility within 100 feet of the mean high water mark of any lake, pond, river or
stream (including intermittent streams)? ☐Yes ☐ No
If you are proposing to replace or expand an existing system, will the new system
serve an actual or potential occupancy increase of the shoreline structure served?
☐ Yes ☐ No
☐ Replacement of an existing _______ square-foot structure with a new _______
square-foot structure. Confirm the existing and proposed use of the structure.
________________________________________________________________
☐ Conveyance of entire ownership
☐ Other (describe)
_____________________________________________________________
2. Does the project involve establishment of a new business? ☐Yes ☐ No
If yes:
(a) Will it be operated at your residential property? ☐Yes ☐ No
(b) How many people will the business employ who do not live on the premises?
_______
(c) How many signs will the business have? _______
W ill they be lighted? ☐Yes ☐ No
W hat will be the combined square footage of the sign(s)? __________
(d) Please describe the type of business. _______________________________
3. Will the project result in any structures over 40 feet i n height (measu r i ng from the highest
point of a structure to the lowest point of natural or finished grade, whichever is lower)?
☐ Yes ☐ No
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(If the structure is close to 40 feet in height, it will be necessary to provide building
elevations [all sides] and a grading plan which shows existing and proposed grade to obtain
a jurisdictional determination.)
4. Will the project result in the removal of sand, gravel, topsoil or minerals from the property?
☐Yes ☐ No
5. Will waste material, such as construction debris, be disposed on the property? (This does
not include soil and land clearing debris generated from onsite construction activities.)
☐ Yes ☐ No
If yes, explain the type and volume of debris.
_____________________________________________________________________
6. Does the property contain shoreline?
What will be the distance from the mean high water mark to the closest new structure or
expansion? _______ feet
If an expansion, how far from th e m ean high water mark is the existing structure?
_______ feet
W ill the existing roof ridgeline height be increased by more than 2 feet? ☐Yes ☐ No
If yes, what is the proposed new ridgeline height in feet above the existing ridgeline
height? _________ feet
7. Will any vegetation be cut within 35 feet of a lake, pond, river or stream? ☐Yes ☐ No
Your sketch should show the size and type of vegetation to be removed relative to the
size and type which will remain.
8. Does the proposal involve provision of any new or additional deeded or contractual access
to the shoreline? ☐Yes ☐ No If yes, provide the number of new or additional lots being
provided access (identify by tax map designation) and the width of the access area.
_____________________________________________________________________
E. SKETCH MAP
(For the purposes of this Inquiry the map does not need to be professionally prepared)
On a separate sheet, provide a scaled sketch map of the property showing acreage,
boundaries, and n atural features and water bodies. Inclu de the location of all existing and
propos ed dev el op men t (including struc tur es, on-site wastewater treatment system, water
supply, driveways, roads, and areas of clearing etc.) It should be drawn at a scale which
clearly shows the location of all proposed activity, with measurements labeled. For a shoreline
parcel, show the lot width along the shoreline and indicate the setb a c k dist anc e from mean
high water mark of any existing or proposed structure and sewage system. Also, provide the
north arr ow, the name of the map maker and date it was prepared.
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F. NARRATIVE (Please describe your proposal)
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
G. CHECK LIST
☐ Have you answered all of the questions?
☐ Did you include a copy of the current recorded deed?
☐ Did you include a sketch map?
☐ Is the form signed by an authorized person?
☐ Did you provide the tax map identification number?
☐ Did you include your return mailing address and phone number?
H. SIGNATURE OF AUTHORIZED PERSON
Note: This form must be signed by a person with a legal interest in the property; onl y
owners, purchasers under an existing contract of sale or their attorneys.
The above information is correct and accurate to the best of my knowledge.
______________________________ ___________ ____________________________
Original Signature Only Date Please print or ty pe nam e
(title if applicable)
If you wish to have another pers on, such as a contractor, process this inquiry on your
behalf, please provide the name and address of that person.
___________________________________________________________________________
I wish to have ______________________________ complete this inquiry on my behalf.
I. RETURN T O:
Adirondack Park Agency
PO Box 99
Ray Brook, NY 12977
Phone: (518) 891-4050
If you are not registered to vote at your current address you may receive a registration form
with the Agency’s response to your inquiry. You may receive government services without
being registered to vote. W ould you like a registration form? ☐ Ye s ☐ No
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