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ApplicationNew Business Area Variance Review month -November 2011 George Mavorauin 1527 State Route 9 Deck already constructed -seeks setback relief. Cross ref: BP 2011-462 TOWN OF QUEENSBURY 742 Bay Road, Queensbury, NY 12804-5902 S 18-761-8201 September 16, 2011 George Mayorquin 4 Madison Trail Hopatocong, NJ 07843 RE: Deck I9S State Route I49 BP 2011-462 Tax Map Parcel No: 27~Oa12 Dear Mr. Mayorquin: I am writing to you in response to-my review of your plans depicting the construction of a deck on the property referenced above. The information I reviewed was the same that was submitted for your building.permit application; BP 2011-462 together with the photographs taken by Bruce Frank; our Zoning Enforcement Officer. ~, Upon review of the plans submitted to this office, I find that an Area Variance will be required to address this after the fact construction. Specifically, -the deck does not meet the minimum p~operty line setbacks of the Rural Residential, (RR 3A) zoning district: .~ , Enclosed please find an -Area Variance application. for you to complete. Please note our established submittal deadlines when compiling your application materials. t t Should you-have any questions regarding the above comments, please do-:not hesitate to contact this office. .- Sincerely, - ~' Town of Queensbury ~~ Craig Brown Zoning Administrator CB/sh ,, -. "HOME C)F NATURAL BEAUTY ... A GOOD PLACE TO LIVE" - SETTLED 1763 • ;~.:' k. ~. _ ; ax Parcel ID Number: Zoning District: ~~ ~i~~~ Area Var nce Revised June 2009 General Information ~ ~~ ~~~ ii X78.-l-2 Detailed Description of Project [indudes current & proposed use]: Location of project: ; ~ S~2 ~ s7-~A7~e. fZo K~c i4~i QK t.e,,,t bv-7 A':• , 1 `Pre-Submission Conferen~ ~I. Tax Map IO ~2.. Zoning Classification -3. Reason for Review: 4. Zoning Section #: Area Variance Revised June 2009 ~e Form X179-4-0401 .2~ -3,9 - ,S,~r~4.4~~~ ~~i~ x=02 t ~~ ~~ X79 3 -~y~ -5. Pre-Submission Meeting Notes; Outstanding Item o Be Addressed Include: +~_=~ ~ Deed t General Information complete ~ ~es / Yes No o `~ ~ :: Site Development Data Complete Yes o Setback Requirements Complete Yes No Additional .Project Information ~ormplete / eS No > FAR addressed ~o Compliance with Zoning Ordinance es No Checklist items addressed s No Environmental Form completed Yes ~ No Signature Page completed Yes No -~ _ ~: Representative: f O~s~/ ~ Town of Queensbury • Zoning Offioa •-742 Bay Road • Queenstwry, NY.128(}4.518-761-8238 Zoning Department Inspection Report Project Name: George Mayorquin - Project Location: 1527 State Route 149, Queensbury, NY Tax Map No.: 278: 1-2 Mailing Address: 4 Madison Trail, Hopatocong, NJ 07843 Area Variance No.:'64-2009 Date: September 6, 201 T Dear George Mayorquin: t- ~~.:. ,ax sa~+fl:o-:P 6. ~::=~'3 e:r: . 7/ During an area variance compliance inspection on September 2, 2011, your project was determined to be En compliance per-the relief granted in your approval for the dwelling and porch additions; however, an additional unapproved deck (approximately 236 sq.ft.) attached to the rear porch was found to have been constructed without any building. permi#.~As discussed with you on the ° telephone on September 2 2011 ou were directed to a I for a buildin permit. --for-- t{~e deck, ~ d . . . you Failure to act as directed will result in an appearance ticket being issued to you for Queensbury Justice Eourt. Should you have any questions or concerns please contact this office. Sincerely, Town of Queensbury Bruce Frank - Code Compliance Officer ~~ ~~ ~ ~ ., ~ ~ s ~.. ~' ~-~' ~.~~ w ~ `~~~ ~ ~ .~ ~ y ,~, ~`~ A •~• ~` ~ 'V ~. ,. ~,:~ .,~ . + r '~. ^ .. WARREN COUNTY ~ PAMELA J. VOGEL, COUNTY CLERK l COUNTY CLERK • ; Lake George, NY 1284.50~_~~~E~-I-~ t~0€~O~r:~,~, t~OL€~t"IE= 2"~`Es1 r'~`i~aE: '~u~ so 20~ oooosora Instrument Number: 2006- 00006073 As Recorded On: June 16, 2006 Deed Parties: MAYORQUIN DENISE R To MAYORQUIN GEORGE U Billable Pages• 3 Recorded By: TIMOTHY J ALDEN ESQ Num Of Pages: 4 Comment: ** Examined and Charged as Follows: ** Deed 16.00 Cover Page S.OU Cultural ~auration 15.00 RP-5217 Resid/Agric 75.00 State Education 5.00 TP-584 5.00 Recording Charge: 121.00 Consideration Amount Amount RS#/CS# Transfer Tax 0.00 0.00 TT 3296 Basic 0.00 QUEENSBURY Special Additional 0.00 Additional 0.00 Transfer 0.00 Tax Charge: 0.00 ~ECOROE6 C4unt9 Glerks Office Jun 1b,itl0i} f4:3bA Pamela J. V49e1 IJarren C4unt9-Clerk ** THIS PAGE IS PART OF THE INSTRUMENT ** I hereby certify that the within and foregoing was recorded in the Clerk's Office For: WARREN COUNTY, NY File Information: Record and Return To: Document Number: 2006- 00006073 TIMOTHY J ALDEN ESQ Receipt Number: 2458 513 GLEN STREET Recorded Date/Time: June 16, 2006 10:36:32A GLENS FALLS NY 12801 Book-Vol/Pg: Bk-RP VI-2961 Pg-288 Cashier /Station: T Riddell /Cash Station 1 <l ~~ . ~~. ~~ "~~ 34 ~ ~ ~'' a~i/Made the ~ day of '~1 ~-~.-~-1 ~ ~ In the Year Two Thousand Six THIS INDENTURE Between DENISE R MAYORQUIN f/k/a DENESE DELLACAVE currently residing at 4 Madison Trial, Hopatcong, New Jersey, party of the first part, and GEORGE U. MAYORQUIN and DENISE R MAYORQUIN, his wife, currently residing at 4 Madison Trial, Hopatcong, New Jersey, as tenants by the entirety as to their one- half ownership interest; and URBANO MAYORQUIN and MERCEDES MAYORQUIN, his wife, currently residing at 66 Essex Avenue, Hialeah, Florida, as tenants by the entirety as to their one-half ownership interest; and as tenants in common as to the other ownership interest, party of the second part, Witnesseth that the party of the first part, in consideration of --------ONE AND 00/100--- -----------------------------------DOLLAR ($1.00) lawful money of the United States, and other good and valuable consideration paid by the party of the second part, does hereby grant and release unto the party of the second part, their heirs, and assigns forever, ALL THAT CERTAIN PIECE OR PARCEL of land situate on the north side of N.Y.S. Route #149 (Farm to Market Road), Town of Queensbury, Warren County, State of New York and being more particularly bounded and described as follows: BEGINNING at a set iron rod at the southeast corner of the herein described parcel on the north boundary of N.Y.S. Route #149 (Farm to Market Road), and being the southwest corner of the lands now or formerly of Lake George RV Park, Inc., Liber 688 of Deeds at Page 116, thence from said point of beginning along the north side of N.Y.S. Route #149 (Farm to Market Road); thence South.84 degrees 03 minutes 35 seconds West for a distance of 112.37 feet to a set iron rod; thence along the lands now or formerly of June and Bartholomew Girard, Sr.; the following 2 courses; North OS degrees, 50 minutes 00 seconds West for a distance of 115.0 feet to a set iron rod; thence North 84 degrees, 10 minutes 00 seconds East for a distance of 139.58 feet to a set iron rod; thence South 07 degrees 30 minutes 00 seconds West for a distance of 117.97 feet along the lands now or formerly of Lake George RV Park, Inc., Liber 688 of Deeds at Page 116 to the point and place of beginning. Said parcel containing .332 plus or .minus acres. Also granting to the parties of the second part all those lands .lying southerly of the last described course and the center of the Farm-to-Market Road, so called. TOGETHER with the ri ht to a trenc and ditch a g y nd the right to lay pipes therein from the aforesaid granted premises, to a spring on the lands of the grantor and the right to take the N.Y. DEED-WARR:A.NTY with lit~~~~ ~~~~~~_~~~~~~ f~C~C~€~EF~`~~ t~o~~~~ ~,~ waters of said spring through said trench and pipe onto the said granted premises and to use the same for domestic purposes; also the right to go upon the land of the said grantor in a prudent ` and careful manner to construct and repair said pipes and ditch when necessary and to do in the same manner such things as necessarily appertain to the occupancy of said rights and privileges; also selling and granting to the grantees herein, the pipe or pipes now connecting said premises with the said springs. EXCEPTING AND RESERVING, from the above that portion of the premises appropriated by the State of New York for highway purposes. Said appropriation having been recorded in the Warren County Clerk's Office on November 11, 2000, in Liber 1191 of Deeds at Page 241. SUBJECT TO any and all covenants, easements and restrictions of record. Being the same premises conveyed by Warranty Deed from Paul A. Zurlo to Denese Dellacave, said deed dated December 15, 2000, and recorded in the Warren County Clerk's Office on January 12, 2001, in Book 1200 of Deeds at Page 30. Together with the appurtenances and all the estate and rights of the party of the first part in and to said premises, To Have and to Hold the premises herein granted unto the party of the second part, their heirs and assigns forever.. And said party of the first part covenants as follow: First, That the party of the second part shall quietly enjoy the said premises; Second, That said party of the first part will forever Warrant the title to said premises. Third, That, in Compliance with Sec. 13 of the Lien Law, the grantors will receive the consideration for this conveyance and will hold the right to receive such consideration as a trust fund to be applied first for the purpose of paying the cost of the improvement and will apply the same first to the payment of the cost of the improvement before using any part of the total of the same for any other purpose. In Witness Whereof, the party of the first part have hereunto set their hands and seals the day and year first above written. In Presence of L.S. Denise R Mayorquin (f/k/a Denese Dellacave) ~!'f_,~ STATE OF NEW JERSEY ) ~..J ,. ) :SS: COUNTY OF ~ 5~2.;X ) ~C~LC[~E ~ 24~Et 1 PFiGE ~ ?~ ~ On this ~ day of . ~~ )l~.Q_,, in the year 2006, before me, the undersigned personally appeared _ Denise R Mayorquin (f/k/a Denese Dellacave) personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledge to me that she executed the same in her capacity, and that by her signature on the instrument, the individual, or the person upon behalf of which the individual acted, executed the instrument, and that such individual made such appearance before the undersigned in the City/Town of ~ ,~ ~~a ~ ~ ,State of New Jersey. ~~ NOT Y PUBLIC RENEE K. RESNICK NOTARY PUBLIC OF NEW JERSEY My Commission Ex.~ires June 8, 2010 Record & Retum To: TIMOTHY J. ALDEN; ESQ: 513 Glen Street Glens Falls, NY 12801 n TOWN CAF QUEENSBURY 742 Bay Road, Queensbury, NY 12804-5902 518-761-8201 September 16, 2011 George Mayorquin 4 Madison Trail Hopatocong, NJ 07843 RE: Deck I95 State Route 149 BP 2011-462 Tax Map Parcel No: 278.00-I 2 Dear Mr. Mayorquin: I am writing to you in response to my review of your plans depicting the construction of a deck on the property referenced above. The information I reviewed was the same that was submitted for your building permit application; BP 2011-462 together with the photographs taken by Bruce Frank; our Zoning Enforcement Officer. Upon review of the plans submitted to this office, I fmd that an Area Variance will be required to address this after the fact construction. Specifically, the deck does not meet the minimum property line setbacks of the Rural Residential, (RR-3A) zoning district. Enclosed please fmd an Area Variance application for you to complete. Please note our established submittal deadlines when compiling your application materials. Should you have any questions regarding the above comments, please do not hesitate to contact this office. Sincerely, Town of Queensbury ~; ~_ Craig Brown Zoning Administrator CB/sh L:\Craig Brown\2011 Letters\Denial Mayorquin 9_16_1 l.doc "HOME OF NATURAL BEAUTY ... A GOOD PLACE TO LIVE" SETTLED 1763 . ~", Tax Parcel ID Number: 'Zoning District: Deta ....., . applicant Name: (~Eo2HE MA~f'oQpvul/ .Address: q• M q o~soN f2a ~ ~ No~Afeorve t/,• ' I o~a 43 j Home Phone i q•7 3" Fj01-712$ Cell: 973- Gav-342 Work Phone et7 3' 34~'~ g J'3 0 '.Fax ° E-Mail : ~ee+~t E3/~ Ye~cP~~'~ ete~lwc • ~.+~*+ I j Agent's Name: Address: ~-- _ j Horde Phone Cell: Work Phone i Fax '' E-,mail -- j Owner's Name C~~~IJ~~1q~C~~d1y1 Address 4•M~sD~soN f~4• f{o lar~g ~ o7Y43 Home Phone g73-~0/-7/ 2Q, Cell . " - - q73 -Goo-342 Work Phone q73- 348 - 9~'3v --- --- Fax E-mail - --- - Area Variance Revised June 2009 General Information X78.-l-2~ R2.3A~ 17g•3-a~.o, t?~- 13-o to Town of Queensbury • Zoning Ofrice • 742 Bay Road •Queensbury, NY 12804.518-761-8238 1 Location of project: t~ - ! 52 7 STRTr. 20 Kl~c /4~ K r~+t Cdr 6y`! Area Variance Revised June 2009 Site Development Data I Area /Type Existing sq. ft. Proposed Total sq. ft. - -- - -- - -- - A. Building footprint ~ - Addition sq. ft. - ' i232r~ 1232 'B. Detached Garage C. Accessory Structure(s) ~~Ck- 2 D. Paved, gravel or other hard surfaced area "Z so ~ sa E. Porches /Decks ,, `F. Other G. Total Non-Permeable [Add A-F] ~ ~ ~ 2 ~ t y 2 1 _H. Parcel Area ~ ~ '[43,560 s'q.`ft. > acre] 1 4 ~ ` • ~ I • ~ ~~4,4~:~ _ I. Percentage of Impert~neable Area of Site [I=G/H] Setback Requirements ... I Area... Required `Existing Proposed Front (1] ~G O ~ ~'~. ~ ' ~~'1 ~. Front [2] Shoreline Side Yard [1] 7 5' 44.6 d~ ~. Side Yard [2] Rear Yard (1] f i • Rear Yard [2] Travel Corridor Height [max] - - Permeability _~ ;- No. of parking spaces Town of Queensbury • Zoning Office • 742 Bay Road •Queensbury, NY 12804 •518-761-8238 ~ Area Variance Revised June 2009 Additional Project Information 1. Will the proposal require a Septic Variance from the Town Board of Health? /V 2. If the parcel has previous approvals, list application number(s): _ w~ - ZUO 3. Does this project require coverage under the NYS DEC Stormwater Pollution Prevention Program? 4. Estimated project duration: Sta Date End Date 5. .Estimated total cost of project: / ~pO.~dv ' 6. Total area of land disturbance for project: 3'~- •s ~- 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 FloorA~ea Ratio`jFAR] Waterfront Residential WR 0.22 Commercial Moderate CM 0.3 . Commercial Intensive CI 0.3 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 Hof the principal and accessory buildings or structures on the project site. Parcel Area s . ft. Existin Floor Area sq. ft. see above definition Proposed Additional Floor Area s . ft. Proposed Total Floor Area sq. ft. Total Allowable Floor Area Area x see above table Town of Queensbury • Zoning Office • 742 Bay Road •Queensbury, NY 12804 •518-761-8238 3 Area Variance Revised June 2009 Compliance with Zoning Ordinance Requesting relief from SECTION: _ ~~~~` ,~"t~~f~ Need relief from the quirement(s) listed below which can not be met by the project as proposed. [Check all fhat apply) Setback ^ Buffer Zone ^ Lot Width ^ Other The following questions reflect the criteria for granting this type of variance. Please complete them; use additional sheets if needed. 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? ~s'rR~n r1 ~~ ~• va r'i a n C ~. i •L G n p C'~ Gr h ~ ~ ~ l` ~ rt-r A~ c7-E ~ d F ~h~ r7c ~'9 !, to o~ ~ ~o o ,C ~- ~4 G/e Tr'i M C'~?- 7~ /~ eA-,2 •(~ ~ ,~ry/dC' .~7-~j . ~. Whether the benefit sought by the applicant can be achieved by some method, feasible for the applicant to pursue, other than an area variance? „, . ~" be ,'e r/e. ~ a,~' a~ arc.9- v~-r-i'~'r~Ce i' s ~ bn /~ - _ t'hc~~u~ ~ C~re-/G. -?~ .bane •7~". ewe ver e a ~'~ Q Leh Q // Sv ~ 9 P ~T'~~.-~ (' n~- ~~ ~.(o ~ _ , Tx ~ -~, ... , v g o 3. Whether 4. i ~~ _ l' G ?' 7'h G Dl~ N Si cff- L 5. Whether the alleged difficulty was self-created? 1~ e de c K.- w~ s s.~l ~-~.~ -P.t~2 ~h v ir0~ rn G h ~" L, ~or'l~,ov~ or o(i ~'Txzis d • >-~zv~e r we 7~ ~.. ~~ ~~ -~-a I ~ cured Jn.~.c' ~ _, C~.r?2vif the requested area variance is substantial? e q u~es..~e c~ f~-~ ~4 v~9'r': a h c e ~~s .Svc s n9-r~ ~-,~'~ L Whether the proposed variance will have an adverse effect or impact on the physical or environmental conditions in the neighborhood or district? ~•e ~raAoSed cIa r, Wince r~,'f/ X07- ~~~ec~ v ~' Town of Queensbury • Zoning Office • 742 Bay Road •Queensbury, NY 12804 • b18-761-8238 4 Area Variance Revised June 2009 Submittal of a stamped and signed SURVEY MAP depicting existing and proposed conditions shall include the items as noted below. V.Y :~ I A~~.... -._ ___. ( ~~iv~rvl~ SHOWN ON 1 Title, Name, Address of applicant & person responsible for preparation of drawing -- SHEET # ~'rr~ 2 Deed , 3 North arrow, Tax Map ID, date prepared and scale [minimum 11n = 40 ft ) . . 4 Boundaries of the property plotted to scale zoning boundary , ~~ r''~ 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 - - - ~ WATER 8 SEWER } SHOW ON 1 I -. _ Protect sewage disposal facilities, design details, construction details, flow rates, and number of bedrooms proposed SHEET ~ -- 2 Water supply [i.e. well] & septic on adjoining lots with separation distances to existing or proposed on-site water supply and septic Separation distances for proposed sewage disposal system to well and water bodies J 4 Existing public or private water supply (well, lake, etc.]. Method of securing public or private water, location, design and construction of water su pl inGudin dail water usa e 5 Percolation test location and results ' - -- - - -- C, '; ,PARKING'/ PER EABLE AREAS ~ SHOWN ON Number of spaces required for project including calculations and just cation: existing & proposed SHEET # - 2 No. of existing parking s aces, number to be removed, number to maintain and t pe of surfacing material e.., ravel, paved 3 Provision for pedestrian and handicap access and parking: existing & proposed 4 Design details of ingress, egress;"loading areas and cutting: existing &, proposed .5 Location and character of green areas [existing and proposed], modification to green area, buffer zone to remain undisturbed 6 Lighting, location and design of all existing and proposed outdoor lighting D ~ ADD1TiONAL 51TE DEVELOPMENTANp fv11SCELLANEOUS ' ~, SHOWN.ON- T On-site & adjacent watercourses, streams, rivers, lake and wetlands ''SHEET # 2 Utility /energy distribution system [gas, electric, solar, telephone]: existing & proposed 3 Location, design and construction details of all existing and pro~iosed site improvements includin : drains culverts ret ini g , , a ng walls, fences, fire & emergency zones. and hydrants, etc. l~- ~` otage of bldg. area proposed for office, manufacturing, retail sales or other commercial activities: existing proposed rE: Signage: Location, size, type, design and setback: existing & proposed y-:,. l- f- Waiver Request: provide letter with application requesting any waivers: please reference specific items •. g Commercial/Industrial Development requires submission of Landscaping, Stormwater Management, Grading & Fighting Plans fi. Identification of Federal, State or County permits required for the project together with a record of application for all nece ssary ermits Town of Queensbury • Zoning Office • 742 Bay Road •Queensbury, NY 12804 •518-761-8238 5 Area Variance Revised June 2009 Pre-Submission Conference Form f179-4-0401 1. Tax Map ID ~ ~- ~' ~-- ~ , 2. Zoning Classification /~~ ~~~ 3. Reason for Review: ~,~~~~/~ ~`~j~ /~~ , ~~ ~/~~~ 4. Zoning Section #: ~ 7 / ~ `~~~ -5. Pre-Submission Meeting Notes; Outstanding Item o Be Addressed Include: • Deed ~~es General Information complete !~ Yes No No _ Site Development Data Complete Yes No Setback Requirements Complete es Additional Project I f ti C ~ ; No ~ • n orma on omplete es No FAR addressed Yes Compliance with Zoning Ordinance es to ~ • No - Checklist items addressed es Environmental Form completed es No No Signature Page completed Yes No ~l~i~"r v~ ~,r~G.9-~.y~~t,' lr ~`~/rr= lt~,~~g~ ;,~- ~.v~;~ ~' BaiL~ ~ ~cc,~c. •4 ,~t-~ rner! tiJ /'~~o, To .4ccc.•-,oc+l•9~ .• /'l'! ~! w i ~e ~.S L~ ~a rn l ~r~l•"c . ~".y/lf ~.~-r'c~ ~ o L.~~t .~ /! f 1 C D r ~/O !./J'C. /'pit/ !J/~/ ~1L , ~'~iPr~ /~I $~~t//1- ,bi-o o s~,6oW1' • .T' ice ~. //1/E ' e ,ee/L ~ ~ o~tC. .~ ,8~ mod/ ~e :~ ~. _ ~T OBI r!J' dKF-/1' .1 ~t/.¢~,~Dt*.t~ t~ ~ !',(' W ~•t Der !!/ Cow ..~ rtl.~ aylr/~ /~a~~eLe f /•0 4t c. l~ig7i mace /y!C c ~ . .~"' ~Si~1c^e~l~' .9,~yLo~c-rLe ~?uin © ~~ee•~pyyiy~/ Zo., !,r.~- bo.~~! aria/ .~ !~1 /ylr~+rs~a!rf ~' Staff Representative: `; Applicant /Agent: Date: Town of Queensbury • Zoning Office • 742 Bay Road •Queensbury, NY 12804.518-761-8238 6 ti.. Area Variance Revised June 2009 -~ ~--......_....a..,.,,.o...-. a.~., yr Pronae maPl 5. IS PROPOSED ACTION: • ^ New , ^ Expansion ^ ModificatioMalteralion ~ ' 6. DESCRIBE PROJECT BRIEFLY: ' y 7. AMOUNT OF LAND AFFECTED: Initially acres Ultlmatel acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? ^ Yes ^ No If No, describe briefly 9. WHAT 1S PRESENT LAND USE IN VICINITY OF PROJECTT • ^ Residential ^ Ipdustrial ^ Commercial ^ Agriculture v ^ Park/ForesVOpen space ^ Other • ' a 10,. DOES ACTION INVOLVE A• PERMIT APPROVAL, OR FUNDING, NOW bR ULTIMATELY FROM ANY O,aHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAy7 • ^Yes , ^ No If yes, Ilst.agancy(s) and•penrllUapprovals ~ t1. DOES ANYFASPECT OF THE ACTION'HAVE A CURRENTLY VAUD'PER$tIT OR APPROVAL? ^ Yes ^ No If yea, list agency name and permiUapproval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/APPROVAL REQUIRE MODIFICATION? ^ Yes ~ No • 1 CERTIFY THAT THE INFORMATION PROVIDED ABOVE, IS TRUE 70 THE BEST OF MY KNOWLEDGE Applicantlsponsor name: Date: Signature: If the action is in the Coasts! Area, and you are a state agency, complete the Coastal Assessment Form betore proceeding with this assessment• 14•ttr4 (11!95)-Text 12 PROJECT I.D. NUMBER 1177.20 SEAR Appendix C State Environmental Ouafity Review ' SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART 1-PROJECT INFORMATION (To be completed by Applicant or Protect sponsor) 1 . APPLICANT /SPONSOR 2. PROJECT NAME 3. PROJECT LOCATION: Municipality Coun 4. PRECISE LOCATION (Street addraee nod ...mow :..._...__..___ OVER 1 Town of Queensbury • Zoning OfFce • 742 Bay Road -Queensbury, NY 12804.518-761-8238 ~ Area Variance Revised June 2009 PART 11-ENVIRONMENTAL ASSESSMENT (To be completed by Agency) A. DOES ACTION EXCEED ANY TYPE 1 THRESHOLD IN 6 NYCRR PART 617.4? tf yes, coordinate the review process and uaa the FULL EAF. ^ Yes n N„ 8. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? It No, a negative declaration may be superseded Dy another involved agency. ^ Yes ^ No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, if legible) Ct. Existing air quality, surface or groundwater qualny or quantity, noise levels, existing traffic pattams, solid waste production or disposal, potential for erosion, drainage or flooding problems? Explain briefly: C2. Aesthetic agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly: C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly: C4. A community's existing plans or goals as offlciaily adopted, or a change in use or intensity of use of land or other natural resources? Exptaln briefly C5. Growth, subsequent development, or related activities likely to be induced by the proposed action? Explain briefly. I C6. Long term, short term, cumulative, or other effects not identified in CUCST Explain briefly. C7. Other impacts (Including changes in use of either quantity or type of energy)? Explain bristly. D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CEA? ^ Yea ^ No E. IS THEAE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? ^ Yes ^ No If Yes, explain briefly PART 111-DETERMINATION OF SIGNIFICANCE I;To be corpleted by Agency) INSTRUCTIONS: For each adverse effect identified above, determine whether It is substantial, large, important or otherwise significant. Each effect should be assessed in connection with its (a) setting (i.e. urban or rural); (b) probability of .occurring; (c) duration; (d) irreversibility; {e) geographic scope; and (~ magnitude. if necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse Impacts have been identified and adequately addressed. If question D of Part tl was checked yes, the determination and significance must evaluate the potential impact of the proposed action on the environmental characteristics of the CEA. ^ Check this box 1f you have identified one or more potentially large or significant adverse impacts which MAY occur. Then proceed directly to the FULL F~1F andtor prepare a positive declaration. ^ Check this box if you have determined, based on the information and analysis above and any supporting documentation, that the proposed action WILL NOT result In any significant adverse environmental impacts AND provide on attachments as necessary, the reasons supporting this determination: Name of Lea agency Print or Type Name o Responsi a Officer in Lea Agency it e o esponsi a icer . ignature o Responsi a icer in Lea Agency tgnature o reparer (1 i scent rom res ponsi e o icer) Dale c Town of Queensbury • Zoning Office • 742 Bay Road •Queensbury, NY 12804 • 518-761-8238 8 Area Variance Revised June 2009 Signature Page 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: Variance Site Plan Subdivision For Tax Map No.: Section Block Lot 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: Designates: As agent regarding: Variance Site Plan Subdivision For Tax Map No.: Section Block Lot Deed Reference: Book Page Date OWNER SIGNATURE: DATE: 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: I, 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 ~#,atement/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 I/we 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 hay ad and a ee to the above. ~~~E,yyy~l.~,~'r Sjgnat a [Applicant] Print Name [Applicant] Signature [Agent] Print Name (Agent) Date signed Date signed Town of Queensbury • Zoning Office • 742 Bay Road •Queensbury, NY 12804.518-761-8238 ~ 9