form revised 3/5/19
Zoning Referral Form
Orleans County Planning Board
mail or deliver to:
Orleans County Department of Planning and Development
14016 Route 31 West
Albion, New York 14411
Referrals can also be e-mailed to planningboard@orleanscountyny.gov
Please type or print in space provided, attaching extra sheets if necessary. Incomplete or missing information will result in delays in processing and review.
I. Information Regarding the Town or Village: MUNICIPALITY: _________________________________
DATE: ___________________ PHONE: ____________________ ADDRESS: _____________________________________
NAME & TITLE OF SUBMITTING OFFICIAL: ___________________________________________________________________
CONTACT E-MAIL ADDRESS: ________________________________________________________________________________
II. Type(s) of Proposed Action: _____ COMPREHENSIVE PLAN _____ AMENDMENT TO ZONING TEXT
____ AREA VARIANCE _____ USE VARIANCE _____ AMENDMENT TO ZONING MAP
_____ SPECIAL USE PERMIT _____ SITE PLAN REVIEW _____ NEW ZONING ORDINANCE/LAW
III. Information Regarding the Site: TAX PARCEL NUMBER: _______________________________________
STREET/ROAD NAME & ADDRESS NUMBER: _________________________________________________________________
NEAREST INTERSECTING ROAD: ___________________________ PRESENT ZONING DISTRICT: ___________________
APPLICANT’S NAME AND PHONE: ___________________________________________________________________________
OWNER’S NAME AND ADDRESS (IF DIFFERENT FROM APPLICANT): ____________________________________________
RELEVANT SECTION(S) OF ZONING ORDINANCE: _____________________________________________________________
DESCRIPTION OF REQUEST: _________________________________________________________________________________
____________________________________________________________________________________________________________
Signature of Submitting Official: ______________________________________________________________
This cover form should be attached to all detailed information and documents that the municipal board would utilize to
adequately consider impacts. This typically includes additional narrative and at least a site plan map drawn to scale with a
north arrow, lot lines and waterways, locations of existing and proposed structures and existing and proposed easements or
rights-of-way, the zoning classification of adjoining properties, distance (in feet) of structural setbacks from lot lines, and
completed Agricultural Data Statement and Environmental Assessment Form, where applicable.
For County Planning Board Use Only
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