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Application and Supporting Documents Area Variance [ZBA approved: September 21 2016] Town of Queensbury Area Variance Application REVIEW PROCESS' 1) Required Pre-Submission meeting with staff to determine general completeness of application materials to be held no later than 1 week prior to deadline day. Call(518)761-8238 or(518)761-8265 for an appointment. 2) Determination of application completeness. All necessary information must be provided and appropriate fee(s)paid for consideration for placement on an agenda for that month. 3) Incomplete applications will not be considered for placement on any agenda until all missing information has been supplied. 4) Submittal to the Warren County Planning Board,if applicable. 5) Zoning Board meetings,generally the third and fourth Wednesday of each month. You will be advised in writing as to which meeting to attend. 6) Following the meeting,you will be provided with a copy of the resolution stating the Board's decision on your application. If your application was approved,the next likely step is a Building Permit.Final plans/drawings must be provided for the next phase of review. If your application was denied your project cannot proceed as submitted. DOCUMENTS TO BE SUBMITTED:(HARD COPY&ELECTRONIC) 1 original and 14 copies of the completed application package to include: Completed Application: pages 1-9 completed,signed&dated Pre-Submission Meeting Notes: signed by staff Denial Letter: from the Zoning Administrator Survey: Current Survey: survey map depicting current conditions—sign,stamped,date by surveyor Proposed Conditions Map: The proposed conditions map must be based on a current survey and may by prepared by Surveyor,Professional Engineer(Civil)or a Registered Architect. Area/Sign Applications: must provide a final as-built survey depicting all site conditions and improvements Survey Waiver: Applicant may request a waiver from the survey pre and post requirements. Copy of Deed Fee: $50 residential;$100 commercial ZONING STAFF&CONTACT INFORMATION: Craig Brown,Zoning Administrator crai b gqueensbur Laura Moore,Land Use Planner lmooregqueensbury.net Sue Hemingway,Office Specialist sueh(a_queensbur .net (518)761-8238 Visit our website at www.gueensbury.net for further information and forms. Page 00 WN 'IQ- HF -MIRIVY 74.2 R iqy August 11, 2017 Errol silV06"g P.0. Box 481 Lake Goorp,NY 12845 Kl-': Private Garage oy-pansiork 230 Lookhart Mt. Rd Tax M4pPmvol. 252.-1-38.1 Dear Mr. Silvorborg: I am vnitir#g you with regards to my wvivw of the RbQvP-r@f1Dr=c*d project aW to dwwmoat the w. pont conversations bowemn your fisont; Palo Clothier and Laura Moore,of my offir'rr. Upon my rff ir-w I find that ygvr proposal will tvqv ito an Area Vqrjmw, Use VqTia1Rqr, qr4 Site P14n Review prior to the issuance of a building permit. An Area Vati=c, is n"ded as the proposiDd addition sults in R struvwro in ex ss of tho maximum allowable Nuaiv f"i,- for 4 pflvm g4mgv, A U4 Variance is rioq uired as your plan qg[Is for the construction of an addition to a private garagr, on a puVpj WbPTQ no allowable principal ixsp (5inp,]Q family dwoffing) exists. Site Plan Review is needed for the Ovallsion Of the M'W. I uoOrstand that you or you agents am erring tbo now&sary application materials. A s wcb,Wis 19flor will wivi-,as the necessary Op W IOW for dip pro swing of your applications. Should you have, any questions or wmmWs regarding your application, please dQ not hesitate to contact this office. sinr'eZIJY' Craig Brown Zoning Administrator CB/bA Cc: Dale Clothier I, Oe " Area Variance [ZBAapproved: September 212016] General Information Tax Parcel ID Number: '. ti. d Zoning District: Detailed Description of Project [include current&proposed use]: Current Use: e Proposed Use: t Location of Project: Applicant Name: Mailing Address e 6 izr 1 Home Phone City, State,Zip - Work Phone Cell Phone .. E-Mail: ;41"c.x . FAX No. Agent's Name: : , Mailing Address Home Phone ti City, State,Zip . pC t` /2 Work Phone Cell Phone a `, E-mail FAX No. Owner's Name " g, Mailing Address Home Phone City, State,Zip Work Phone Cell Phone E-mail FAX No. Page I Area Variance [ZBAapproved: September 212016] Site Development Data Area/Type Existing sq.ft. Proposed Total sq.ft. Addition s` ft. A. Building footprint 7D B. Detached Garage C. Accessory Structure(s) D. Paved,gravel or other hard surfaced area " E. Porches/Decks F. Other G. Total Non-Permeable [Add A-F] H. Parcel Area [43,560 sq.ft./acre] 3 I. Percentage of Impermeable Area of Site [I=G/H] V7 0D 2 Setback Requirements Area Required` Existing Proposed Front Yard.[I] Front Yard[2] Shoreline Side Yard [1] �� r Side Yard [2] 75 Rear Yard[1] Rear Yard [2] Travel Corridor — s Height[maximum] rte/ Permeability aj Number of parking spaces _ 49 Page 2 Area Variance [ZBA approved: September 21 2016] Additional Project Information 1. Will the proposal require a Septic Variance from the Town Board of Health? 0111 --- . 2. If the parcel has previous approvals,list application number(s): 3. Does this project require erage under the New York State Pollutant Discharge Elimination System(SPDES)Permit Program? —Yes/_No 4. Estimated project duration: Start Date: End Date: 5. Estimated total cost of project: 6. Total area of land disturbance for project: Floor Area Ratio Worksheet FLOOR AREA RATIO (FAR) -- The relationship of building size to lot size, derived by dividing the total building floor area by the lot size in square feet,yielding a percentage. Zoning District Symbol Floor Area Ratio[FAR] Waterfront Residential WR 0.22 Commercial Moderate/Commercial CM/Cl 0.3 Intensive A. The combined area of all square footage, as measure from exterior walls of all structures on the property,including all floors of the structures, garages, basements and attics with more than five (5) feet of ceiling height and covered porches. Building square footage does not include: Open deck, docks and that portion of covered docks extending over water and one storage shed of one hundred twenty (120) square feet or less. Any additional sheds will be included.(See"FLOOR AREA RATIO"). B. Commercial or industrial: the total area in square feet as measured from the exterior of the outside walls of a building or structure, and when applicable,the sum total of all floor areas of the principal and accessory buildings or structures on the project site. Parcel Area sq. ft. Existing Floor Area sq. ft. [see above definition] Proposed Additional Floor Area sq. ft. Proposed Total Floor Area s . Total Allowable Floor Area (Area x [see a tab]e] Page 3 Area Variance:Town of Queensbury Compliance with Zoning Ordinance Need relief from the requirements listed below which cannot be met by the project as proposed. Other: Garage exceeds the size permitted in RR-5a zone. 1. Whether an undesirable change will be produced in the character of the neighborhood or a detriment to nearby property will be created by the granting of this area variance? The project will extend the current use of a building for the storage of automobiles.The site was originally Gillis Poultry Farm which was then leased to become Top of the World Autobody, and then as Performance Trailer Manufacturers.The property was sold to Silverberg in 2008 and cleaned up of debris and car and trailer parts.The existing building was renovated leading to a significant upgrade of the property and overall enhancement of the neighborhood. 2. Whether the benefit sought by the applicant can be achieved by some method feasible for the applicant to pursue, other than an area variance? The benefit of constructing the addition to the existing garage is that it allows the owner to continue needed renovations on the interior of the existing garage.The addition will provide space for storing these classic cars which cannot be exposed to the weather. In addition,there are few properties that would be able to support this kind of garage. 3. Whether the area variance is substantial? The variance is not substantial in that it represents a 27.4%addition to the existing building on a 6.55 acre parcel.The setbacks well exceed the requirements for the addition and for all but the south side of the existing building (60 foot setback in a 75 foot zone).At 92%, the percent of permeability exceeds the 75% limit for the RR-5 acre zone. 4. Whether the proposed variance will have an adverse effect or impact on the physical or environmental conditions of the neighborhood or district? The use of the building to store cars belonging to a car investor has resulted in a positive impact on the neighborhood.There are no employees and the only activity on the site is the maintenance of cars from time to time. Access to the site and potential buyers or sellers of cars is by invitation only. This represents a far less intensive use than residential use.This use has existed since 2008 without incident and is compatible and in harmony with the neighboring houses. The entire area around the building is an open space lawn surrounded by woods to the north and west.The south boundary has a vegetated buffer with native plants and shrubs that serve to support the wide variety of wildlife in the area. 5. Whether the alleged difficulty was self-created? The property has been used commercially since it was a chicken farm before it was subdivided. It was purchased at the time when the building was being utilized as a trailer manufacturing facility.The existing building was still in reasonably good condition and able to be utilized for the use the owner was seeking. The existing building does not lend itself to boat storage since it has interior support posts and low ceilings. The building does not meet any modern engineering or aesthetic standards for a residence or a contemporary commercial building. Conversion to a residential use would therefore be infeasible due to the prior manufacturing uses, shape of the building (originally farmer construction for housing chickens in 1961), and renovation or demolition costs. Page 4 Area variance [ZBA approved: September 21 2016] Section 179-14-030—Application materials Application materials and site plan drawing is to include sufficient information for the Board to review and provide a decision. The applicant is to provide a site plan drawing(s)—a survey showing existing conditions,a proposed conditions map(see page 00 for specific criteria)and include any other attachments that address A-D as applicable to the proposed project. A. General Shown on Sheet# 1 Title,Name,Address of applicant&person responsible for preparation of drawing z5 2 Deed 's 3 North arrow, Tax Map ID, date prepared and scale [minimum: 1 inch=40 feet] 4 Boundaries of the property plotted to scale, zoning boundary 5 Principal structures, accessory structures with exterior dimensions "' 6 Site improvements incl. outdoor storage areas,driveways,parking areas,etc.: existing& proposed 7 Setbacks for all structures and improvements: existing&proposed 8 Elevations and floor plans of all proposed and affected structures B. Water& Sewer Shown on Sheet# 1 Project sewage disposal facilities,design details,construction details,flow rates,and number of bedrooms proposed 2 Water supply [i.e. well] &septic on adjoining lots with separation distances to existing or proposed on-site water supply and septic 3 Separation distances for proposed sewage disposal system to well and water bodies 4 Existing public or private water supply [well,lake,etc.]. Method of securing public or private water, location,design and construction of water supply including daily water usage 5 Percolation test location and results C. Parkin /Permeable Areas Shown on Sheet# 1 Number of spaces required for project including calculations and justification: existing& proposed 2 No. of existing parking spaces,number to be removed,number to maintain and type of surfacing ,25 e`c' material[e.g., gravel,paved] 5 3 Provision for pedestrian and handicap access andparking: existing!&proposed , 4 Design details of ingress,egress, loading areas and cutting: existing&proposed 5- 5 Location and character of green areas[existing and proposed],modification to green area,buffer zone to remain undisturbedc ? 6 Lighting,location and design of all existing and proposed outdoor lighting D. Additional Site Development and Miscellaneous Shown on Sheet# 1 On-site&adjacent watercourses, streams,rivers, lake and wetlands ✓ ' ' "� 2 Utility/energy distribution system [gas, electric,solar,telephone]: existing&proposed 3 Location, design and construction details of all existing and proposed site improvements including: drains,culverts,retaining walls,fences, fire& emergency zones and hydrants,etc. 4 Square footage of bldg. area proposed for office,manufacturing,retail sales or other commercial activities: existing&proposed 5 Signage: Location, size,type, design and setback: existing&proposed 6 Waiver Request: provide letter with application requesting any waivers: please reference specific items 7 Commercial/Industrial Development requires submission of Landscaping, Stormwater Management, Grading&Lighting Plans 8 Identification of Federal, State or County permits required for the project together with a record . of application for all necessary permits = G` ' Page 5 August 14,2017 Craig Brown Planning Department Town of Queensbury 742 Bay Road Queensbury, NY 12804 RE:Survey Waiver for Silverberg Application for Site Plan& Use Variance for Parcel 252-1-38.1 Dear Mr. Brown: This letter is a request for a waiver from the requirements to provide a surrey map with topography with the application for a use variance.The most recent survey was completed in 1993 on a map labeled "Map of Survey of lands of L. Rae Gillis".We believe that the site plan provides enough details about the building and property for the board to understand the project. Secondly,the existing building far exceeds the setbacks required in this district on three sides and the proposed addition meets all the setbacks.The Town of Queensbury approved the 60 foot setback on the south side of the existing building in 1994. A visual inspection of the property will illustrate that it is virtually flat in and around the project site. In addition,we believe that the closest definition in the Queensbury Zoning Ordinance for the existing land use is"public garage"due to the fact that Mr.Silverberg does use the garage as an investment and therefore buys and sells 2-4 vehicles per year. Thank yg for your considjaration. t f t Dale R. Clothier,Agent for Errol Silverberg 3 Deer Run Road Lake George, NY 12845 tclothier@nycap.rr.com -4se.Variance [ZBA approved September 21 2016] Ark, Pre-Submission Conference Form/Section 1799--9-040 1. Applicant Name: 2. Tax Map IDLocation: 3. Zoning Classification 4. Reason for Review: 5. Zoning Section#: C( 3 '� (�'�(�-. Q'Z 0 6. Pre-Submission Meeting Notes: Provided Outstanding; Please provide by Deed General Information complete Site Development Data Complete Setback Requirements Complete �/ X �C�C�� ,{ r (lS CQ/ f/v,/v Additional Project Information Complete FAR addressed t Compliance with Zoning Ordinance Checklist items addressed Environmental Form completed Signature Page completed c1 I _4 0/ -Q L (7PS o� z�G( -se,, S E/C ! c `-� e S "� �C• �CS r �t c�C a-,'— C w S v vi C r 4 C> 41 � C fi C!—C,C, k- 2'e—CiAc�,�c.,C � Z(Y-)se L/�,P_ L r Staff Representative: artC. - Applicant/Agent: PP g Date: Page 6 Area Variance [ZBA approved: September 21 2016] This page includes the 1.)Authorization to Act as Agent Form: 2.)Engineering Fee Disclosure; 3.) Authorization for Site Visits; 4.) Other Permit Responsibilities; 5.)Official Meeting Disclosure and 6.)Agreement to provide documentation required. OWNER'S AGENT FORM: Complete the following if the OWNER of the property is not the same as the applicant: Owner: Designates: as Agent regarding the following: Variance Site Plan Subdivision For Tax Map No.: Deed Reference: Book Page Date OWNER SIGNATURE: DATE: APPLICANT'S AGENT FORM: Complete the following if the APPLICANT is unable to attend the meeting or wishes to be represented by another party: Owner: "2�1 Designates: %° _ as Agent regarding the following: Variance V11— Site Plan Subdivision_ For Tax Map Nom Deed Reference: Bo k 'Page� Date OWNER SIGNATURE: % ATE: 2.) ENGINEERING FEE DISCLOSURE: Applications may be referred to the Town consulting engineer for review of septic design, storm drainage, etc. as determined by the Zoning or Planning Department. Fees for engineering review services will be charged directly to the applicant. Fees for engineering review will not exceed$ 1,000 without notification to the applicant. 3.) AUTHORIZATION FOR SITE VISITS: By signing this page and submitting the application materials attached herein, the Owner,Applicant,and his/her/their agent(s)hereby authorize the Zoning Board or Planning Board and Town Staff to enter the subject properties for the purpose of reviewing the application submitted. 4.) OTHER PERMIT RESPONSIBILITIES: Other permits may be required for construction or alteration activity subsequent to approval by the Zoning Board or Planning Board. It is the applicant's responsibility to obtain any additional permits. 5.) OFFICIAL MEETING MINUTES DISCLOSURE: It is the practice of the Community Development Department to have a designated stenographer tape record the proceedings of meetings resulting from application,and minutes transcribed from those tapes constitutes the official record of all proceedings. 6.) AGREEMENT TO PROVIDE DOCUMENTATION REQUIRED: 1,the undersigned,have thoroughly read and understand the instructions for submission and agree to the submission requirements, I acknowledge no construction activities shall be commenced prior to issuance of a valid permit. I certify that the application,plans and supporting materials are a true and complete statement/description of the existing conditions and the work proposed, and that all work will be performed in accordance with the approved plans and in conformance with local zoning regulations. I acknowledge that prior to occupying the facilities proposed,I or my agents, will obtain a certificate of occupancy as necessary. I also understand that Uwe may be required to provide an as-built survey by a licensed land surveyor of all newly constructed facilities prior to issuance of a certificate of occupancy I have read and agree to the above. 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Hu'iitiln a Ftp Z i,pM LL IL IL ILLL IL IL LL LL tp to N t leg 'C� mo $n =2 Ul =<JefaXxq C' W <F- i] � Z C14 S ry � 5 y 1 Errol Silverberg Proposed Public Garage Addition:Town of Queensbury Site Plan Review& Use Variance 4 fa View of Property from Lockhart Mountain Road Easterly View from Rear of Existing Building View South of Gillis Property from Driveway View of Siverberg Property from Lockhart Mountain Road Errol Silverberg Proposed Public Garage Addition:Town of Queensbury Site Plan Review& Use Variance AR _. 595.4156 _`"t►.p:� VE S1� 1 9 Garage Interior with Support Posts Garage Office J'Sl LICA fYr aF?Ei Business Lisence South Side of Existing Building Errol Silverberg Proposed Public Garage Addition:Town of Queensbury Site Plan Review& Use Variance ■.+yrs -_ North Side of Existing Building Site of Building Addition (North Side) 7-711- — Front Entrance of Existing Building Front Entrance Looking North Errol Silverberg Proposed Public Garage Addition:Town of Queensbury Site Plan Review& Use Variance 817412017 Warren County Parcel Viewer 811412017 warren County Po,W Viewer A S 1 . 5 rtP� or i J '' r Initial Extent Zoom In Zoom Out. f Bird's Eye Street View identify - Initial Extent Zoom In Zoom but Bird's Eye Street View Identify WARREN COUNTY PAMELA J. VOGEL COUNTY CLD E�U ���?'rPAGE=AL �+�20#3 Lake George, N Instrument Number: 2008- 0000605$ As Recorded Oen: July 22, 2008 Deed Commercial Parties: BUNTING WILLIAM To SILVERBERG ERROL8illabie Pages: 4 Recorded fly: WILLIAM J WHITE ESQ Num Of pages: 5 Comment: ** Examined and Charged as Fallows: Deed Commercial 37.50 Cover Page 5.00 RP-6217 Commercial 165.00 TP-W 5.04 Recording Charge: 212.50 Consideration Amount Amount RS#/CS# Transfer Tax 800,00 200,000.00 TT 2774 Basic 0.00 QUEENSBURY Special Additional 0,00 I Additional 0.00 Transfer 800.00 t Tax Charge: $00.00 i s i IES Camts Clarks Office Jul 22x2= 12:ZDP Pasela J. V6961 Varrsn Casts Clerk I E **THIS PAGE 13 PART OF THE INSTRUMENT 'k* I hereby certify that the w thin and foregoing was recorded in the Clerk's Office For: WARREN COUNTY, NY File.Information: Record and Return To: Document.Number: 21008- 00006056 WILLIAM J WHITE ESQ Receipt dumber: 81477 BRENNAN S WHITE Recorded DatetTime: July 22, 2008 12:20:49P 163 HAVILAND RD Book-Vol/Pg: Sk-RP VI-3597 Pg-208 QUEENSBURY NY 12804 Cashier/ Station: S Steers 1 Cash Station 3 ------------------- i5x.. Er' 5..: . ,.t � M,• vi � a [D 'bP CL CL � � y 0 4 a. C� aC cam ' 6:. Q v Ut v v r-r b fiEr' � yzo �. x tTlr 10 co 0 0 tri,� to ►.•,, � ��, , � �141 +� r' �• v, � tri � m M CD ` (D �' o d o. Com" d a r � � , cu cn 00 fit"' ' cv p �• aolit ._ r vi; CD CL CL 0 o COCAM o CD CL QQ s �� � ���,,•, � t'D F•h y'' 0" Q'' � �•+� � �+ to ,� :... Er Ei O Cr7 CD Q% COD cu co *O Q+ tea, o yr O CL CLa V V �. Ov n. o wA W p m -� tri AM :y.,:. � � � � rte► (� � t'i} � / � � .� r. Q • T la r 4A; ,::: '�ti"" Vii '`�• � �. �M WF goo y YK. ��� l �' `car ,��.,. ren• ° � �,..f C-' w fl r' �D 5 £fir x ■ P. r fl► �s- tee: C) 110 4, o � "* w' a= Ia. O. 0 aq -40°Q oc CL rA Q O0 r c0om TA W : o cn0w o cqM Az o y� z ° .c 4 p- R *0 g � y ' p, cmc 04 c '. wo (JI Yt�.. t.. ra:. Q 0 � r� to o t✓ � 9- . 0 r� r "�. t7d ash ' , r � 0 NNF--► oc �. o v'► a oCA ° a © w... A C/! w r•+ ch N � Ets p. Q W N p 4-it m 9 0 Ey ,•� d C? V, 0QQ y LC C C7 © O O rte..• " ', N ',p 'rt' ,�r ,,,,. „�*_ " r'�i r co 89 �-►. ►-«, to c� p .—• p `'� © • v� a• Etan 00 N �' � �-► r' �•+ ��., ,�.* `tEC�� ''h p v 0 4, CA P. N .ti c va r�. kA _ o - Q *• ° G ►-•i p.. ,,.� � � Cxf � � NN � EpCAW O tTl 00 r•hN �l � {� n Ctp� � t� � � {�hp tEp'D rQ+ cwh �h � 'y `L+ r--1. E�L 00 �., e-* Q �j p Q ty� e-+ CG O ►7 �°+a `•� �• (D co ' a to � � � � WC-' � , ... ... � - � ;� tTj00 d cm- lid , ' cn� f mN - r �-- rA o as ` A. `°•�"° a b o a Gds . o cn `r/ "MT's ((I/�i iAC+ V �Q c . a . Q, ca k� 0 0000FO W 3 �.y v CE �y NO z Ew, w n rr.+yy CD 010 o #�+ � b ,... w-•• CL QQ Mo :.. I'✓ �.... G�1 r % (1) Cao ry �� � �[/� V? �• 180 S Q 0 �D q, o c, w � CODrto OPL � o �.. - Ch o 00 w 00 os 0 CL p 5A CD >.; 010co Short Environmental Assessment Form Part I w Project Information Instructions for Comb ietin Part'I -Project Information. The applicant or project sponsor is responsible for the completion of Part 1. Responses become part of the application for approval or funding,are subject to public review,and may be subject to further verification. Complete Part I based on information currently available. If additional research or investigation would be needed to fully respond to any item,please answer as thoroughly as possible based on current information. Complete all items in Part 1. You may also provide any additional information which you believe will be needed by or useful to the lead agency;attach additional pages as necessary to supplement any item. Part 1 -Project and Sponsor Information Name of Action or Project: Project Location(describe,and attach a location map): e;�1�rpll� //6// Brief Description of PProposed Action: GZ r % ' `�e_lt Name of Applicant or Sponsor: Telephone: >'i " E-Mail: Address: City/PO: State: Zip Code: 1. Does the proposed action involve the legislative adoption of a plan, local law,ordinance N9 YES administrative rule,or regulation? If Yes,attach a narrative description of the intent of the proposed action and the environmental resources that may be affected in the municipality and proceed to Part 2. If no,continue to question 2. 2. Does the proposed action require a permit,approval or funding from any other governmental Agency? NO YI✓S If Yes,list agency(s)name and permit or approval; ! ❑ 3.a.Total acreage of the site of the proposed action? $_ acres b.Total acreage to be physically disturbed? acres c.Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor? ;sem. acres 4. Check all lane) uses th occur on,adjoining and near the proposed action. D U an EgRural (non-agriculture) ❑Industrial ❑Commercial Residential(suburban) Forest ❑Agriculture El Aquatic []Other(specify): ❑Parkland Page I of 3 5. Is the proposed action, NOYES N/4 a.A permitted use under the zoning regulations? b. Consistent with the adopted comprehensive plan? ❑ 6. Is the proposed action consistent with the predominant character of the existing built or natural NO YES landscape? [a-ff 7. Is the site of the proposed action located in,or does it adjoin,a state listed Critical Environmental Area? NO YES If Yes, identify: ( (� 8. a. Will the proposed action result in a substantial increase in traffic above present levels? Flo] b.Are public transportation service(s)available at or near the site of the proposed action? c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action? 9.Does the proposed action meet or exceed the state energy code requirements? NO YES If the proposed action will e rr ements,des ribe design atures and technologi 4 El 10. ill the proposed action connect to an existing public/private ater sup ? NO YES If No,describe method for providing potable water: s, /zr� % �'' I I. Will the proposed action connect to existing wastewater utilities? NO YES If No,describe method for providing wastewater treatment:, (� 12. a.Does the site contain a structure that is listed on either the Stateor National Register of Historic NO YES Places? b.Is the proposed action located in an archeological sensitive area? 13.a.Does any portion of the site of the proposed action,or lands adjoining the proposed action,contain NO YES wetlands or other waterbpdies regulated by a federal,state or local agency? ❑ b.Would the proposed action physically alter,or encroach into,any existing wetland or waterbody? ❑ If Yes, identify the wetland or waterbody and extent of alterations in square feet or acres: 14. Identify the typical ha kg`t types that occur on,or are likely to be found on the project site. Check all that apply: ❑Shoreline aForest ❑,_,A,�ricultural/grasslands ❑Early mid-successional EJ Wetland El Urban [)'Suburban 15..Does the site of the proposed action contain any species of animal,or associated habitats, listed NO YES by the State or Federal government as threatened or endangered? ❑ 16.Is the project site located in the 100 year flood plain? NO YES 17.Will the proposed action create storm water discharge,either from point or non-point sources? NO YES If Yes a - a,Will storm water discharges flow to adjacent properties? O [ YES b, Will storm water discharges be directed to established conveyance systems(runoff and stor rains)? If s,briefly describe [-1 NO YES Page 2 of 3 18.Does the proposed action include construction or other activities that result in the impoundment of NO YES water or other liquids(e.g.retention pond,waste lagoon,dam)? If Yes,explain purpose and size: ❑ Ef 19.Has the site of the proposed action or an adjoining property been the location of an active or closed NO YES solid waste management facility? If Yes,describe: F] 20.Has the site of the proposed action or an adjoining property been the subject of remediation(ongoing or NO Y completed)for hazardous waste? 1-1 If Yes,describe: ❑ I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE Applicant/sponsor name, � � Date: Signature: PRINT FORM Page 3 of 3