Planned Parenthood Application General Informa—tion
Tax Parcel i ': � ___ _�_� '
Zoning District. 0 FFI r,' i0
Logit size. � PmPProposed Use, P)6 t'417t MA- 1115A I Ub �
Current Use.
1 "ViT1e, f- AS, NEW 05PIAIAIL, OFFIcS,
Project Location: PAL'I�
Applicant Name FPAPJNrb F ? T
1Z Is 01'
Home Pbo6i Calle p
'
Phone _ 74 - Fes,
"Tgenfs Name:, ,fir `r A4 d e,9Address: '
t- ',
fi rma ''Ph,one CII.:
Work Phone Fax
7E-nn,EaOl I E
wnee Names " Address,
I-f TM phCell
Work Phone Fax
E-mail
V'fi Vin',
MAR 1 w Site Plan Review Revised March 201:14 2
Town of Queensibury Planning Mice-,742 Say Ro@dl-Queensbury,NY M04.616-761-8220
F QUE NS AidRY
Site Development Data
Area I"hype, Urig sq,. ft Pr¢o osedi 0tai sq.ft,
Addition sq.,ft.
A. Building taint
'B. Detached Garage
i
. i
avedl graved of other harry surfaced area
t
PV^
�7 ther(i.e. boathouse® sunder k, etc.),
G.Total Nlon-Permeiex tAdd A-
H. ar e l Area 143„560 sq. ft./a, rel
L Percentage of Impermeable Area of ite [i® +iii] /' 0/ r
Setback RgqUjrgmqqLS
Area Required Existing Proposed
Sapp PPOF-
Front[I
-7 7 �
FrontA�V�7- j CO 7 C, f FBI. 19
Shoreline
Side,Yard [I)
Sides Yard[ ]
REW Yard 11 1
Rear Yard[21
Travel Corridor I
” � r `. �
height(max)
'e rme, biii 5'74 D
No. of parking spaces
Oiiiii M'
'down ofQueensbury Prlui ffice,74 Bay Road,Quieemsbur',NY IZ8 -518--761-8220
Additional Prolgot Information
I Willll the proposal require a Septic Variance from the Town Board of Health? too
2. If the parcel has, previous approvals, list applicaflion number(s): .. .........
3. Does this project require coverage under the NYS DEC Stormvvater Pollution Preventlon, Program?
/V 0
4. Estimated project duration: Start Date ur End Date
51. Estimated total cost of project: + 000
6e, .. 1,06,e 7WP 0. Z5' +r4WF—
., Total area of land disturbance for pr0j, Ct,
u ArRatio Worksheet NIA
FL AREA RATIO (FAR) -- The, relationship of buildingi We to lot size, derived by diViding the total building
floor area bly the lot size in square feet, yielding a percentage.
Zoning District Symbol Floo r Area Ratio,[FAR]
'Waterfront Residential WR 0.22
Commercial Moderate/Commercial intend ve CM/Cl i 0.3
Main Street NIS 0.3
X The mrablned area of all square footage, as, measure from exterior walls of all structures on the property, including ali
flours of: the, structures, garages, basements and attics with more than live (5), feet of ceiling height and covered
parches. Building square footage does, not indude: Open deck, docks and that portion of covered dock's extending
over water and oine storage shed of one hundred! twenly (t g) square feet or less. Any additional sheds will be
incluidad. (See"FLOOR AREA RATIO"),
B. Commercial or industrIal: the total area in square feet.as measured from the exterior of the outside walla of a building
or structure, and when eppilicable, the surn total of all floor areas of:the principal and acoessory buildings or 5tructures
on the project site.
A. Parcel ,Area sq.,ft.
B. Existing Floor Area ............ sq, ft, [see above deffnifibn]
C. Proposed Additional Floor Area sq, ft.
D. Proposed Total FI ollor Area sq. ft.
E., Total.Allowable Floor Ams (Area,x [see above table[
*ilii' D la larger, than E, a variance or revisions to your plan may be needlecl. Pleaconsult
w/Staff.
Sit,o Plan Review Revised March 014 4
Town of Queensbury Plannibg Office, 742 Say Road - Quiei.-nsbury, NY 12804 •518-7'61-8220
WARATE 9AS?OtJeP`5 5H"-;r.
§ 179-9-00' fin Ape rov ALI. Thg Planning Board shaill nOt aPPrOVi a 3'ate Plain unless it
first delermines that such site plerii, meets jh,e following Standarcls, Please prepare respionses to sac of the fo)kwkV
toplii
r�STANDAPDS
A. The pf"OposedprolecAlurthers.u risconslis ntv&ht'hepolicies Plan.
i.8 Ila I W—slajndardrasset
forth In flarai
B. The pmposedprojecA cori ;iiviO al'i"Irerenle,01: 1 joludingthe site plan
ptn
of this section 1he dlrnansjwall�buAk.Bandl density regWiagonis of the,zwIng dlstrkt ons which it is proposed to,be localed(Article,5 amid Table 1).
theqppajoble reqm[rements of all other Ai that OPPIV.
C.
The site plan 7er-'=urai;liaspedestrian Z
to and from,the ped rtttlm paths orsIde;Zksiconnecled to
adjacent areas.
D. The she plan must corwlorrrrm loi Chapter 1,3,61 i5awi and Sewaae Disposal, Chapter 147 U10ii OfinagOrment LOCaC Gw—, arid—001or
applic,able bcalt lavys-
E., Iha proposed ugi§almall be In harmony"IAh tnie!general purpose or Intent of this:Chapter,specjllcally taking into mount lime luctWon,character,
and size of"ttia proposed use and this,de.%011on and purpose:of The i5strict.In vi such useis piroicii the nature ismirt intensity of,the:
Octili to ba involved In or conducted In conneckin wO the proposed use amid the nahire and rate of any Irwrai In #119 burden on
supportiN,public seni and,i!aolllMes viii will loi Itia approval of the proposed use.
fine stalilishrment,rnalrrtemenoa endl opereticrr of th proposed uvea milt utict create puutri4lc lna ands fronn trahlo aft oningisslion, r me 3611 r ing
F:. of YeWaclas andfor equipment or be othenidse,delminmental Jig the health, sall'isty or general welfare of pens residing or wi to 'fie
nei&ghborhaod or to The generall wellaria of the town.r Traft access and clecOAMon, road imerseclions, road and driveway widihs,and Iraffic
controls M11 be adequate.
diamitaimleallm: an�icipatedlob geneirate0by
—6.- Off-street pi�lfllijiii wnd loading tai M 1.115 apprapdaliely located 12,2 11::.�j�5 �ryangmd�aridwfli;iiiiiiiiiii'
diia,now use. The establitshment of vdhizte lini betwi parking areas of adocent pificipeffiea si prodded where feasible, This lurtliers the
Toviii goal of reduolng curb cuts and reducing corligeslion, A tworty-foot Niiii canni Is reqluifed, if adjacent properties are lelgier
undeveloped or preViously developed vdituit ha,yiwfrg made pmvlslon for luturis Ninkei Nihon a ftilura connectlon must be 5dandlied and
pricvIcted for h lihe altei plan under review for sur�fi future Nnkai when the gnme,aTisiss.. The plenning Board may requtra i that the
applicant has made content vi adjaci propert'j owners for purposes of ociercitnating linkages wilm adjacent properties.
I scai aesthetic,e. �;et,Wildlife,hiskomic.recreaticinal!or open space
H. The puecl still natnayO Z u71'lid'Naadwerse:impaict upain Die 1,011ir!I: -ollaig
jasources of IIi tow or the Adirondack Faik of adequate,provlskrn of suppoffiri giacl�ani sei made necessary by the
pri IaWmiq Into account,the commerew, industrial, resIdeni recrealWirial or other barialits that might be diedvad Imam the pmject. to
rnaWng the diaterni l-miraurvier,thio Planning Etolard shah coni lhuse fetors perilfri to the project cQnlalned In time development
considerations set licii hisran under§1,79.9-080 of,"s chapteri,and In so doing,the Flanning5card shag make a net overall evalui�n,of
,the pimjoot in m4lion w pie development objective$,and general qtddahnes sot forth,In§1791-9-1080,of this Article,
t. Tlisw pr lkway g JUV1.1res,Voti o
slon for and,arrangari a pedestriall l irali'lli access: an,J c Ilrulatien,.wa
and overall pade rii corwenNenua shelf be safe and adequate for pedesfrilan,movermilariL Ped'OsIrlan cormaciluns been adjacent adtas
ahall be provided to ancourai peclestirtan use,
us iii� i,icii i a id
—jame—rdraini taeffillazi i.iiiiii,prevent an Timacasie of post ii di�00 I! l�i pre-dewiakpment
'5m'm'�
Qminage of lhO8Aa shall recharge,ground water to the extent practical, Surface waters Ilowing offlujila$halt not degrade snYr!streams of
adversely afti drainage on adjacent propaWt@s,cr pubNo roads. F=aelji shall be In confatimance wiiiih the drairi standards of Chapilef
1147 of the Town Code and the Town of Queenabuiry SubdWislon Ngui%tions where applicalofe.
K IS;water supp(ly and sewaQa diisposal,Fact Ifies be acirnquate and All and rorrant ii"i1juhroniii ;sei ro,16 t7 Department
of Health regulations and Chapter 186 of the Town Code,
i. o1l;71'i]'N@;' a.;ai sirreening shall effeedw y provide a
The ai "e and orit!:i''i 1 9!1 a 11 ii i,a i r'I 11 11:1 lie !"W
PI I , shri�and CAii ptantlrrga® pandscapiq
visual arxVor polse buffer barneen the applicants and adjolpling lands, Including the max[inum rateri of eklistIng wegetagon and
malintenance,Including impliamment of dead or deceased plants»
Wzy nrequIreiri at amefgismi&mice providers'.lanes,Ornari zMand Ike hydraWnls:will SCIffWate end anneal
susceptible jo p ding, floodN ari aii Will inlri or avoid
itWCTL[fPs ........... ftcap5nq In,ansa susearlible 10 p
ini 10 the niaxIii ax-tant prectl bra.
slari end perfdrrnerroa atandardls ofPA
Site Plan Rei Revised March 2014
Town of Queen bury Nanning Office-742 Say Road-Queensbary, NY 128104, 18;.7 't-8221
j79-9-a6O,AM11caff1M.Lqr Site Mali, view
Absen't aniy waiver or waivers, an application for Site Plan Review,shall include the fo![Owing:
REOUIREMENTS
A,vicinity map drawn at the scala That show o the relalloni of the proposal 16 exisliro community ledlilles;which Mi or serve it,
rueb as roads,Shopping areas, Schooi eto.r The map sballl also,shin ell properties, li$enkhy omofa, sijibidi4fislon5i, street$,and
easements YjAhiq S110 feet of this Pliftiparly. SwO,a Sketch may be oi.Wmposed on a UTted $tales Geological SuryeY MP Of(bin
arei
L
B The site plan shall be drawn at a scale of forty feet to the inch(li"=40 feel)or sLxh other scale:as the Planning Board may deem
appropriatis,on stand' 24'x 36'Shoals,with contipwallon on,BY;`x I10 sheets as necessary for wrinen IrwTorm ation., The infoTmialiiari
"PL""
Misted below shall be shown on the she Plan andl contlinualloa Shoets.
Marius tiros prof timndariesn date,north arraw,and scale of the plana.
D Nama and address of 1ha owner of reoced,developer,and Seat of the"Oinaer,arctlilaidt,or Iandscopa archilea It the applICOnt t%not
the:recorid Ower,a letter of authorization Shall tie ratitilred from the 01
E The lotiallan and u"of all existing and Prnposedstruolurar within live property,iinpliuding all:dimensions of height andfloor area, all,
exterior Onlrances,and ell anticipated Miss addiflons and allerations.,
F -r,he tlon of all present and proposed potAlo and private ways. off-s4rSat parhing auras„ driveii 0S 11torage areas
s4awalks,ramps,Ouirbs,paths,,larigh4aping,vmIK o,d fancez, Localbn,type,and Screening dojails for alll waste disposal contain ars
she,41,al&o,be sahown,
Th;bac oi height.InhansIty,and biulb type incandescent,e:kq-)of all extemal fligntft fiKtiaos. The dirocOon of lillumination
and mi to eliminate glare canto adjolningpropertles must also be shown in compliarice With§t7 -6-M.
H The location.height,S[ze,maredEds,handl design cd all proposed Signs,
'rho lacialJon cd all present and proposed utiliV systems Inoluding:
1. Samoa or Septic System;
2. Water SUP*system;
3. Telaphione.,cable,end ffclflcal 5!ystglms;� and
4. Wrm drainage ureteric Including ex[Sling and proposed d;aln lines,culvefis,catch basIns, beadwaft, andliwalls,hydrisini-9,
manhol'es,,and dfatnakSe 5males.
Plains tD prevarit the pollution of surface or groundwater, smaon of soiM liothidtjrjflg andi 411ter cionstfui;1on, e;Kcessive runoff, and
flooding of other propenles., as applicable. A Stomweler poll'otion Prevention, Plan (5 Ppb for all land developm,ant actIvi6es
j,SXclud[ng agIftultural scihillas)on the,ell& that Tesolts In land i;l5sturbance of I-acre or more. A SWpfP shall comply "Ah RM
requireni of this DIEC sPOES MS-4 Oarbaral Permit and Chapter 147 of the,Taman of Quaiansbury Code, it shaff be ar 1he
dircradan,of the.Planning Board as tDi vdietber aSWPPP or art erosion and control pan Shall be required to esila plan review project
tarW disturbance of less than I-we,
K
-fact coi fi or suoh citherucctoor Interval as ExIsOng amid proposed topography at tym the Planning Soi allow, All
alavatlicins shall refer to thanearest United States CegStal and Geodetic Bench MarK 11 any portion of the!porca[Is witbil'n the,100-
year ficodipleini the area vAl be shoun,and bass flood elevations given. Areas shall be indicated Within lhe propased she and wlthki
5D feet of the proposoCI SAO w1i 804 removal or filling Is required,showling dine app,mix;mate volume in GvVo yards.
L A landscapia Plan shi allegisting natural land features That may inlivence the,desio!n of the proposed Lisa auxth as roof:CU401"Si, d>
stands of Irees'sin gia tri eight of more Trachea In[Hemejer,forest cover,and water soorces.,and all proposed changes to lhese
features Including Sim and ty q0ifi floodplains,pies of plants. Water soi Include ponds.lairs,wedands and wretercourses,,a
and drainage retention areas.
M Lemd Use Diabict boundaries within WO last or the sl1dis peTtmi shall tie drawn and idanflail on the r1la P[afl, SO wall OS 8iny
peVes,0,""'=89 P MWr
rs
Site Pian Rev Iew Revised March 2014
Toviiin of Queensbury Planning Offift&7142 Bay Road Queensbury,,NY 128014-518-761-0220
RJ8QUIRrzMENTS CONT111i
Traffic flow pattalmr.wiAhin the siti entrances and e*W,and loading 0M ung ding areas,..9.1;well aGourb crags on,Iha!340 and W%ii
100 feet of Nhe site. The i acel may,at its discreflon,require a delalled Iraft slud.y for lard developmeros or for thZe in
Ileavy,traft air s„vvh[rh shall Include.
k�,end an, 11 peak
huur baitlo
1. The projeded number of motor vishilida,Nos,to enilier cir leave line Sita, esfimaled for waeWy and annual]peak hzyu; trafflo
IMIS,
2. The pr*cfed ITaffiC fAOW' pagem inclotling vaNrudiar movemenis eta major inter"Wicins. likely 10 be affected by 1110
proposed use ofthi
3, 7he Iripacit of IWIs,fraffiG on levels;of serwke on abuttling public reels and al effected Interajaclicins. Edsting and proposed
weekly and annual peak hour fraft levaW and road capacily lei shi%ft alsobe givtn.
For new consIrluclion or alferallorLs to any structure:,a lablle cuntairifing the followInig WOM-adort shaAl be lnduded:
s. Estiffirated area of structure to be used for paTticular pLgpQses such as relaill operallonoi storage,e4i
2. Esffmalod mai number of emp'ayees'.
Maximum sealing capaolly.Viiihara:applicable.;and
4-. Number ret parkinj spaji ex[sVnl;N and required for the Intended use.
P 1. Floor Plans, -
proposed nuclure(.s)an A1
2, Elevations at a scale of,one-quarlar Inch equals one toot(1/4'�I &0010L for all e4i facades,Of,Me P
aloma � A
altarallions to or exp as oil:exIsIling facai showing cles�gn featum and indicaOng Shue tyke aftd C r of larials 10 beused.
Cf -Soil ri weer siuppilywell and,percolation Neat restAW,and storm as needed to dulervaine and mININate prqjecl
impacts,
R Plans for disposal of cignstructian and demcirilion,wasie,eaher oak-aIle or at an,approved crisilmsal facility,
S Plans for snow ramovi Including 11waflon(s)of on-site snow,Btomqo-
T An,Frwironmerdal Assessment Form� 'n.85 required by the SEQFIA.ragutaijons,,with Part 1 camplemd by the Applicant:shO be,
subm.itted as part Of the applIcakl0m 11 the proposed.project mquireg a spectal use permit and an EAE has been submitted in
cnnjuncdon moth a special usia permit appErAtfolin,a duplicate C-Af is not required for the sile plan apPlcaii0n-
Ub a
U an application is,for a parcel or partals on which moto than one!use is pmposect,the aPPdlcgTA may G i I si n900 aPOPation f r
ed such,uses provided the proposed use3 am:accurate delineated on a 0e plan drs"n pursuant to Ina requlremarft set IGAII
above. The Flannilng Snard,may grant the appllaaticn Wilh respect 10 soma PTOPOW uses,and T1011 others. For purposes of ri
an EippfcaNlion (and (or 8EQRA,campliame) all proposed uses Di 13 rimgja parcel aron contig was parcels shall be Considered
tcrgottrer.
V A btriatnanrafive statement.an baw,ths,project proposed for w furthers or is coneatent with the vislon,goals and policies in the,
T owi OomprelhensiNe Plan.
5[te PIM Review Revised March 2014
Town of Queensiloury Planning Office-742 gay Road,Queensloury,NY 121 4 -518-764-8220
Pre-Submission orufer -4.0401
I. Tax Map ICS -
3. Table ot AllowedUses ( A ik'° .µ�w� o+" �: � �°, ��L ,<�" ;p� is subject to Site Plan Review
rd'traerre Section
U. Pr submission Meeting Note%Outstanding itemne To Be Addressed tnclluc
Deed Yves o
General i fe allensurnpietoe 'des No
Site Dleveieperi�mt Data om plete „ "Yes NO
Setback Requirements, eimplfete ` 'eg No,
Ad' ifiram�ai Proje t dnGorrmutiom urmpi �e —7 Yes - No,
*Qqv n" i- ?F. PPP Programa t" yes No,
FAR orlwsheet comp lei �� "� 9e�
Standards add'fessed yes ��""" No
hemkil t it rns addressed yea; No
Environmental Furan completed V, YOs ,N
Signature Page rompletad Yes � N
e ;y,,
Irt �v r w �� rv7"_ :R
i ,. � f)"z % 1- fie
':.
�11-
p •W,
way Ir",
c el C' w Ic'„ dai
P
iib m l mus: rovide mr;I iIntant PP ,�n 9 Form, QBE leftit nuMbgr,
dr tiee-of._Teu matien (NOTA
StaffRepresentative:
Ap tJAgent: �jqiep f> EOPT, 0 PW V" Pqb SV P Le,�ty i
Date: " h
..........L114—
MePian Revivised March 2014
Town mt' ueerreiaury Ptanming Office 742 Bay Road, Queensbury, NY 'i ZBO,4.518-761- Z
Signature Page
This pa IneWdes the 1.),AuthorizaWn to Aot as Agent Fonn:: 2.) Eng!lneering Fee disclosure;' 3.)Authorization for Site
Visfts, 4.) Other Permit Hesponsibi[ities; 5.) Official Meeting Disclosure and 6%.) Agreement to, provide documentafion
required.
OwNER's A(7EENT Fow;
Complete the folillowIng ff the NEN of the property is not the same a's the applicant
Owner.
Designates,.
As agent regarding. Variartra_Site Plan—Subd[v[sion
For Tax,Map No, SectionBlock Lot
Deed R —eference: Book — Page Date:
ANYUCANT's,AsENT Fww,
Complete the following if the APPLICAKTis unable to atdend the mee,111ng or,wishes to be represented by an0thOT party
Owner pl-A 0 JJ a,0 -F"
L_EAE I �,-,�t> MVS A WLL- "DAN
%Jr
-PY AI r, Af,,'-Co4,jLR-�
Designates: 4 A ,dajf�T'
As agent regarding- Lance__X__Site Plan—Subdivision,
For Tau MapNo.: 'Z4,I&LU—Section I Blcick. A.?- Lot
Dead Reforenoe: « Book 'ZO 7 Pa I Date
APPUCANT SIGNATUDATF-
RE
2.) gHgTWERING FErz DISCLSUR Applications may be raWrred to the Town consuilling engineer for reVl" of seplic digin„
storm drahago, elo, as determined by the Zoning oT Planning Department, Feles, for engineering review services wHI be charged
dIrecUy to the applicant,. Fees for englinearing review valt not exceed$ 1.00D Without notification to the applicant.
1) AMORA119ALE9B SUE VISITS. By Signing this page and submitting the application materials attached herein, the Owner,
Applicant, and hisfherAhefr agent(s) hereby authorize the Zoning Board of Planning Board and Town Staff to enter the subject
properties for the,purpose of revEeWing the application sulbmftted.
4,.) 1 HER PERMIT RESPONSIBILITIES. Other permits may be required for consAruction or afterallon:activity subseclpent to approval
bar the Zoning Board or Planning 5oard. It is the applicanf s responsibility to oblain any addibDnal permits,
OF"-O"Atr,MEEMQ_MIN'UTE�'ap_L'�CLO�' UR�EIt the practice offt oommunity0evelopment Department to have designated
stenographer tape record)the pfcceadings of:meetings resulting from application,and minutes transcribed from those tapes conaftles
the official record of ti'll proceedings.
110 R
BESIVIENT TO PROVIDE 009-OFF-RIA _ N--EQUtR - 1, the undersigned, have, thoroughly read and understand the
instructions for submission and agree to the subTnissioni requirements, I acimowledge no construction activlUes shaft be colmmenced
prior to Issuance of a valid permit. I certify that the applicalibn. plans and supporting Materials are a, true and complete
statemeflUdescription of the existing conditions and the work proposed', and that aW work will be performed In aCCOrdOTICS wlthi Me
approved plans and In,conformance with local zoning regulations. 'I aofrmowledge that prior to occupying the foci lilies proposed,I or,my
agents,will obtain a cartifloale of occupancy as necessary. 1;also,understand that ljAxe may be required to provide an,as-built survey by
a licensed land storveyor of,alt naw ty constructed facilities prior to issuame of,a cerifficate of Occupancy
I have and!agree to fte 11
nd'ag ""
z )"41T141 e'00
T r 1 Applicant] Print Name[Applicant] Date�sged
A4 eeoom !�Zzl /I
Signature[Agent%e Frint Name[Agent] Date signed
Site Plan Review Revised March 2014 9
Town of Queensbury Planning Office,7428ay Road-Queensbury.NY 12804-518-761-8220
61'x20
Appendix
Sliall ElivironnaenlalAssessment Form
Instkrpti a r 'orJeff
Part t m Projett l t6ormatien. The applicant or project sponsor is rrvsponsible Nor the completion of Part]. Responses
barna„part of the application for appm 'w al or funding,are smx'b tct to public review,and may b subject to further Veriflaaflon.
Complete Part l based on lnnf rmwvatiomn cumrrentll,yp evailable, If additional research or investigation nvow ld be needed to filly
respond to any item,please answer as thoroughly,as passible based an,current information,
Complete all Renis in Burt,L You may idso provide any additional Information which you heli e,,will be needed by or useful
to the leant agency;attach additional pages as'necessary to supplement arty iternm.
"art i Project and pioansasr lmtFormation
Name ut ate cti tt+r Project t p, p'd fNA* 'PT 0[ It k,d W i -an ,y S
Vroject Location(describe,andattach a location rnap)I
15+1, tlAl
Brief Description of Proposed,Ation.
Name ofAppl°mcant orSponsor; Z"elephone: - '�'-9;��3
A7 E_MaJ
,
Address.
10 0 '9M1"C eK9AFT J
Cityr 'avw "dat:e. Gp Code.
0$W'JF4V
1.Does the proposed action only invo Gve tete lslative adoption of a plan,local lave,ordinance, NO
YES
administrative rule,or regunlation7
if Yes,melt anarrative description of the intent ofthe by d action and the environmental resources that
may bye affected in the municipality and proceed to Part'2. If no,conlinue to question 2.
2. Does the proposed actdon require a pornmit,approval or funding from any othor governmracntal Agency? l O YES
ifYu,dlst agency(s)name and permit or approval..
PLAN *-PPROVAL-
3.a.'Tolot acreage of the site of the proposed)actiort? acres
b.Total acreage tobephysGcadly`distuebed? 4$ VLe'A-3 . srtaes
c.Tbtal aoreagprojeot site aerial inay centiSmous properties)owned
or controlled by the applicant or project sponsor"? '� perea
I
4. Chaolt all land uses that occur on,adjoinirug and hear the propos
ed action..
a Urban a:Rural non-a ku,dture) a Inadlus'tri I X ornmerdal C)Residential(suburban)
0 Fortmt O ptricuultore 0 Acloadc, a Other(specify);
a Parkland
Pei I of 4
S. Is the proposed action, It DZIS NIA
a..A pemitted use:sander The zoning regualationas--'
b.Consistent with the adopted comprehensive piliarf?
. is the proposed actii-on consistent with the pred;tnirruinant eheracter of the existing bunl It or natural NO YES
landscap '
?. Is the site orthe proposed alofion located in,,or does It adjdln,a state lusted Critical Environrneratal Area? NO 'des
If Yes,ldeanti e
fl. M.Will tine prual action result in a substantial increase in traf o abcnne present levels? NO LYES
b,Are public transportati[an service(s)avaliainie at or near the site of the proposed action?
c.Are any pedestrian accommodations or bloycle routes,available on or near site of the proposed action?
„..mm
9.Does the proliosed action meet or exceed the;state energy-,cadJe requirements?' G'0 YES
If the proposed actfCn will l exceed teryutirernents,describe.design Ieatunrm and t-eciniolo ies:
10. Will the rpaction connect to an existing public/pill%water supply? NO YES
If Yes,dim the existing systern have ca aelty to provide service? M NO N(YES,
If lie,describe method for providing Potable water
I the proposed action,connect;to
ng wastewater
11If Yes.does the existing system have ncapacittyr to provirdetser"ai(l 13 ESi �'�+� i
. ll
If No,des ribs method forrovidin aast ater treztrna nt;
In �ww^
12. a,.Does the site contain a structuare.that
is licked on either the Mate or Nattiiatnai Register ol"Haskorfic No YES
Places,?
Is the proposed action located in an archeological sensitive area'?
13.a. 'am Does
any ns or reion,ofthe egerlsiteos �e gated �roposed fAderal or].:ends adjoining the proposed action,.=twin N
y" , tale or local adel ,
h,W'mild the proposed action physically alter,or encroach into,any existing wetland or waterbody? .
It Yes;,identify Ilia Wetland or watcribody arta extent ofalteradons in square feet,or acres,:..
habhAt
14. Identify
In dine typical l Forel D Early avid-sa�cc�esse�na�
types that occur
rVcaltuurall rtassl nsfound on theat apply:
13 "wetland: fl Urban Xsubijilban
l i,boos the site ofthe proposed action contain any species of atni tna.l.,or associakad habitats,fisted WYES
by the State or FederalI government as threatened or endangered?
16.Is the prix ect site located in,the 104)year flood plain,? NO YE
X
1�, mill throe propaosed,actioin Create skorara row star discharge,eitlaem frrrrn pCirtt Cr non-point soarCess @@O ES
if Yes,
a.Will storm,water 4ischarges flow to adjacent properties? XNO 0 YES
b»Will storm water discharges he directed to established Conveyanca:syr.sterrns(runoff and storm drains)
If Yes,briefly describe: %N,013 YES
Page 2 of 4
18.foes rho proposed action incluade constrao(lon oT other activities that resink in the impoundment of NO
water or otter liquids, (e.g„retention pond",waste lagoon,darn)
If Yes,explain purpose,and size:
19.Has tits site of the proposeul action or an odjoirairng propel been time location of art motive or closed
solid waste filit '
If Yes,,de ribe.
X Has,the site of the proposed action or ars atlJoirning pmperty been the subject of mored latioun,�o-ng�'ng or RRO) Y
completed)for hazardous;waste's
If Yes,describe:
C AFFMMTHAT THE INFORMATION PROVU)ED ABOVEIS TRUEA"A ,'CM.,llllATE"i<`O'THE BEST OFMY
KNOMME 644,Awu
Applicanifsponsor n :e. /M e-o044, Date. " s
�.
�'ipcuaraure,
part 2-Impact Assessment. The Lead Agency is r•esporuusible for the o,orrmpietion of Part 2. Answer all of f"olloming
uluaestiens in mart 2 using the infbrrnation contained in Part 1 and other matearials,submitted by the project sponsor or
otherwise available to the reviewer, When ainsweirins,the.questions tine revi,twer should be guided by tlae concept,"Hane my
responses been reasonable considering the scale and owtestt of Che proposed at:tlork?"
No:,or Moderate
sro'uall to large
Impact Impact
May may
occur oe�nr
>I. Will tha proposed action create a material eonflict with an adopted land use plan or;rmo n
Nguulotions?
2. 'drill the proposed action result in a change in the uric or him nsity of use of land7
m Will the pro poscd action impair the character or dual ity of the eaistins,community?
4, Will the proposed action have an impact on the envirou'uarnerntal characteristics War:caused the
establishment of a Critical Envipremneutal Area(CEA)?
5. ''hili ilne proposed action resmuit in an adverse dhanp in the existing level of traffic,or
affect ex.i ting itnlstraeture for mass traunsk biking or walkway?
fr. "Dill tlne proposed;acdon cause an increase In the use ofeneurgy and it fai is to irtoorporate
reasonaluiV available enpTU consaervado n or renewable ens o ortaarnitiea
T. ''hili the proposed,action impact existing,
a.public I private water supplies?
b.,pub]io�private wastewater treatment until[des?
S. Will the proposed aotion impair tb*character or quality of i potianwt historlc„arebaeological,
arcMtm mural or aesdtetwc rescuuroes?'
9. 'i?a"ill the proposed action result lira an adv me change to natural resources, wetlands,
nu'aterbodies,groundwater,air quality,flora and fauna)?
Page 3 of4
No,or Moderate
.
srnap'l to large
impia,ct impact
may rraaiy
occur occur
IQ. Will the proposed aetittn result in aro In rease'in ilia potential for erosion,,ffloodipg or drainage
proob bans
11. '"a4'ill the proposed action create it hazard to environmenlol resources orb Liman heQalttt'
Fort 3-Determination,of significance.. The LOW AgAncy Is aresap ions ible III the completion ol'Par't 3. For every
question In part that was answered"moderate to large impact may oc":i",or if there is a meed to explain w tyr a particular
element of they proposed aotion may of wwil I not result in a significant adverse environmental impact.„please complete Part 3,.
'wart 3 should„In sufficient detail,iltentify the inrp=t,including any rraeiasucres or design elements that'rave been included by
the project sponsor to avoid or r ace impacts. Part 3 should also explainhow the i td agency determined that the irnipact
may or will not bo Significant,Eadh,potential impart slt�ould be mses�sed considering Sts set n&probability of ocourrirl�,g,
duration" irrewerslibiIity',gcoagraphie scope and magnitude, Also consider the potential for short-terra,long-tiarm and
cumulative inipacts,
IQ Check:this boat if you have:detarmined,based on the Informatlon and analysis above,and:any supporting documentation,
that the proposed Eotloru may result iio a ne orMore potentially large or si nifieatvt adverse impacts and an
environmental impaotstatement is.required,
o Check this boar if you have determined,based on the infbrrnation and analysis above,and any supporting,documentation,
that the proposed action wllll not result In aaty significant adverse enviironi nental impacts.
Tante of Lead Agency Date
Print or Type Barrie of Responsible Officer in Lead,, goncy Title..of Responsible CffF°aeer
i
Signature of Responsible Officer in mead Ap noy Signature ofPre arer(al"ditl'erent from responsible tvt: o-er)-
Page 4 of