Laura Feathers Application � a 16 x nv J
ar�
>an � n��
Site Plan Review Application FEE"i 2 11 2016'
Lj
ReiJew „K
,ppliaant and/or agent small meet with Zoning Administrator to determine type of review needed"
Pre-submission mesting with staff is required todetermine general completeness of application materials (to
be held no later then 1 week prier to deadline submittal -Call (5 18) 761-8220 fed°an appointment).
Application submittal: one (1) original application package, one (t) deed anot 14 copies, of the application
package with the application fees'
Determination of,ap,pilucation Completeness,and placement an and agenda
Planning, Board) mrueetin s are generally the third & fourth 'i-ueaca of each month, You Will be advised in
writinig as to which meeting to attend.
Followingthie meeting you Wit be provided with a copy of the resolution statim the Soard's decision on your
application, it your application was approved, the next likely atop is: a Building Permit. It cror application
was denied your project cannot proceed as submitted.
Tee: $'100-010 (0 to 10,000 f.); 0'= (10,001 to 30,01M s i; $500.00 (30,0011 to 10101,000 ,fl), $1,000,Ojo
(100,,000+
ZoninAContar formation:
Craig Brown, Director of Planning, Zoning & Code Compliance r u�eensbuau ,n t,
i..a.ora Moore, Land Use Planner ccr ru yet
i
Site Plan Revi;ew Revised March 20,14
Town of Queenab�ury Pd nuMnq Ogee,742 Flay Rbad•Quounsbury. NY 1�2804. 618-7'e1-8220
General Information
Tax Parcel ID: FE13 2 4 2015
"TOWN 01-' QUEE[NISBURY
Zoning District: C PLANNING OFFICE
Lot SlZer.'
Current Use; rgtaO
Proposed Use: n-noe), Ey +4n e seo,f. C-n t- ik C0 J.A_X
k 2 1 1
Project Location: n m 11, der
Applilcant Name Address: rA"AWI Fu L.Ae_o " C'e-AI-4f-
Laueo_
Home PhoneCell[: eV4^vn,r__ y 53
( -2 7, - -1 . 1
Work Phone —Fax
E-Mall: if 45A 19 a 53 13 q
Agent's,Name: Address:
Home Phone celf:
work Phone Fax.
E-mail
Owner's Name: _-7d—dress b%4, 11 2-tv C) cor
A'vb oLA N I i LI a"I
Home Phone, Cell
Work Phone Fax
E-mail
pbcn 60 ��,�rz6evtwe�&p men t In le,
Sfte Pan ReAew Revlsied Marcb 2014 2
Town of Queensbury Planning Office-742,Say,Roafd-Queeinsbury,NY 12804 a 518-761-82201
Site-Develo ment Data 2 x
Area I Type Existing Sq.ft. 1 P posed Total q. .,
Additioa s .ttt.
A., Building footprint ?A rL 4A
i . 5hed Garage
C. accessoryStructure(a)
D. Paged, gravelor other surd surfaced-'area '
1,1 Zary .
E. Porches/Decks
F'.. Other (i.a. boathouse, sundeck, etc.)
I G.Total Non-Permeable [Add A-F)
� 2. t C7528th
H. Farce[Area [43,660 q. ft.I acre
I. Plercentage of IrrMmeabia air Rt' lite [I=G/I�
l .'S I I
c.
Setback ,t.airn ,
Area Required Existing Proposed
r
Front[1)
R'V el Cl S
Front [ ]I
Rt Cl i 1
Iharehlne
fide Tarin [1]
u
Side Yard [
acA a
Rear Yard[1]
Rear
i rauI Corridor
Height [�max]
PareabIil�t
No. ol" arkin g spaces
Site Plains Reviewer Revised March�2014
Tow n of Quieembury Planning Ofi: •742,Bay Ruud'>Quieensbury,NY 12804°518-761,82W
Additional Project ilrnformi tion,
I. Will the propuo al require a, SepticVariance from the Town Board of Health?
. If the ar eah; a r ioupr v ls, list application rurnbur ) vi,a
3. Does this project require coverage under the N CLEC toren °gat r Pollution Prevention Program?qgram'
r�, 2
Estimated project dulratinn. Start Date End Dat . _- '� � 2.0,1 6 4- 171
51. Estimated d total cost of project.
Vii. Total area of land disturbance for project.,
Floor Araa--Ratio Worksheet'
FLOOR ARE,A RATIO (FAR) -- The relationship of butildIng size to lot size„ derived by dividling the total building
floor area by the ]lot size in squarefeet, yielding,a percentage,
Zoning Distril t ymbo] �106r Area Ratio [FAR]
n aterfroint Residential' l
Commercial l' od rate/Commercial Intensive /C1 0.
Main Street
A. The comnbined arca of all square footage, as rmeasura fern exterior wails of all structUTes on the property, including all
floors, of the structures, garages, basements and attics with mnorus than five 1(5), fest of calling height and covered
porches. Building square footage dloes not includis: Open deck, docks and that portionof ravened docks- extending
over water and one storage shed of one hundred twenty (120) square feet or less, Any a,dditiornei sheets, will) be
included. (See"FLOOR AREA, RAT 11 ").
B, Commercial or industrial, the total area in square feet as measured from the aXtarior of the ouWda walls, of a building
or structure, and when app icaWe,the sura total of,all floorareas of this Principal and accessory bVildings or stnicturss
on the project site.
PA�L�Pa,,�IoelArea i .
B., Existi aor mea
�. eee,boedeflruitiuoru]
. IP'ruo od Additional Floor Are, sol, ft.
D. Proposed'Total Floor Area . tt
E. Total Allowable Freer Area. (Aron see above table
lf: D Is larger, thiiarli E„ ai variance or revisions to your plan may be needed. Please consult
/stall.
xiite Plan IRevie:w I evil d Merch,2011
Town of Queensbury(Planning Officw 742 Bay Ruud• Queenbury. NY 12804° 518-7161-8220
179-9-080Requirements fpr S 'fp �r�rrvat. "ha,Pj rtrlj Board hall to a~approveS tie Flom unless if
first delermines thef were site plan meets 1fte following Standards., Please prepare responses two each of the kttotrlrang
topic$,
STANDARDS
A. Ills proposed protect furilhars or isconsistent with the policies of the ro,wn"s Comprehensive Plan.
.. Thwa proposed project compiles with all othenr requ mernts of this Mapter,linofuding the site plan review smndandls asset forth in Paragraph p i
of this section,thog dimeasienal,bulk„and density regulations of the zonirag dWstrict in whUn 1t Is!proposed to be'b ated[Article:; arwdl Table 1j',
the appircaWe requirements of all mer Atholes that apply.,
,, The seta plan encouragas pedestrian aclMty frntemallly arndu It practicable.to and frormw the site wriith padestriarn 5tb or r ewelkscGnneetedto
adiiacent areas.
D. The sine plan must ccrwtorrn to Chapter 136 Sewage arra Sewage Disposal, Chapter 147 °Sloan water Management Local Laww„ and other
appllr ble local law% SJ I
the proposed use shall be In hermooy With the general purpose or Went of 111ts Chapter,specifically taking into acrournt the location,character
and alto of the proposed use and the descripilon and,purpose of the dis'tridt In which such use is proposed, ttwa nalurro and Inteinskyw of the
actfwf s to, be involved in or conducted in connection ,with the proposed use arnd the foli ire arta rate of any increase in the burden on '
supporlfhg pndatfoservices.arnd faculties which VIII follow the approval of the proposed use. f ,z
F. The establishment,maintenance end operation of,the proceed use will not create pma.nblic he'arils trorn Wfil41,traffic congestion,or the patkiing
of vehicles aindlur equipment or be otherwiss detrimantat to '[he health, safety or general ww'edarn of persons res lrmg or working In the
neighborhood or to the general welfare of the tow no 'Trefflo eooass and clrculagon„ road lnterwc5o ns„ road and dr vuwwray widths.and traffic
controls w i tae adegwal& %,V tn. A ll y'- aa4 4 z
G. Of•stTeet par kft and loading facilltles wyIN be appropfttsly located and arranged and sufficient to meet traffic anddpated tot gaeneTataed by
the nuewr use. The establishment of vehicle links between parking areas of adjacent propeatles are provided where feasible, This furthers the,
Towwres goat of reducing curb cuts and reducing congestion. A twurentyr400t.wide connection is regWre , If adjacent propedles axe efther
undeveloped or prevIouslyF developed wwIlhout hawring made pmvislon for future finkage, then a future conrieoticn most be Idendt ad and
pro wioed Torr in the slit plan underreview for such future'linkage when the lime arwsss. 'rho Planning Board may regulra proof that the
applfcent has.made contact with adjawcem proper^obwnars for purposes of ccordtnatiragp lirnluages with adjacent prppentes. p4
I
H, 'The project shall not have an undue adverse knpao„t upon the rnafUZZ scenlo,aasthnwtlo,ecolowgfcal.wwtldille,hl orio,recreational or open space
resources of the Town or the Adkondack Park or upon the edectuate proviisimli rad supporting facffitles and services made:neness"'by the
project, ta,Rfrng fnto aomnt the caommerclat, inudustrtal, residential„recreational cw other benefits that might be:derived) from the project. In
making the delermination hereunder,the Plawininug ISoarod shaft consider those factors,pertinent to the projeot contained in the development
consWerations set forth herein under§179-9X080 of this chpptar,arid'In so doling,the Planning Board shall make a net overall evaluation 6J
the project in relation to tlnia development otgeclNes,and geneural guldetines suet froirgh in§ t794)-060 of this Atcle. r-. ,!tq 44,Wc, t e (*,
I. The pmvIsionfor and arrangement of pedestrian traffic access and drcuPation.walkway structcros,control of Intersections%POh vehicular traffic
and overall pedestrian convenience shall be safe and)adequate for pedestrian miumemenL Pedestrian oorrrmectfons b"eMeen adjacent sties
shout be provided to encourage pedestrian use. � t Cl- L-301 16
J', ' tormvw ter drainage facilities.will prevent art increase of past development drainage flows as compared to pre-development drafnagle 11'a ns..
Drainage of the site shall TechaTge.nand water to Rio extent pracdcal., Suurfame waters flowwIng ofd-site shell not degrade any straaTes or
adversely effect drafniage on adjacent propertiea or pUlAc,roads. Faotlifies shalb be In conformance with the drainage standards of Chapter
14'7 of the Town Code and the Town of Queensbury Subdhrlslon N9411allons Where appglcabte, t4,
i
K. The water supply arm(+sewa a disposat lazliuitles will be,adeguale and wwltl meet all applicable and ownrent fe:rt,uairemuer set forlh by,Department
of tfealth regulations and.Chaplet 130 of tho'Towrn Code. f'ad
L The adequacy, type and arraundguemernt of trees,shams and armor surltabfe plantings, landscaping and!screaning shall effeallvafy prov$de a
wisunall of fir noise 'buffer bet ween the appl`ircaros stool adwjoiniing lands, In~wcludIng the maadmum Tetenitorn of earfettng 'vogelatioam and
maintenance,Including replCacement not dead or deceased plains..
fw'l, Fire hatter,,amergency zones,arurl titre hydrants w 1l be adequate:and,meet the meads and requirements of emir- noy sery M prmvidlars„ rJ
N. The design of strualure , madwaye and dandscaptrtg In eraas susceptible to por4ri g, flooding andlor erosion wwl'it minimize or avoid sutcfn
impQcto to the MWIMuam extent practicable.
0. The alta plan conforms to the design.standards,landscaping standardis and perforimarkoe starWizv s of this chapter. r4JP,
Site Plain Review ReVIsed March 2014 5
"Town of Oweenisibury Pllanntng Oft'iQ&742 Day Road)•Queensbury,NY'' 1280 -5168-761-8220
179-"50 Aunficalf-lan fqLSjk f 201L_f Leyiew
Absent any waiver or waivers, an applica,tion for Site Plan, Review shall include the following:
REQUIREMENTS 'Sheet
A A vicinity map drawn at the scale that shows the relationshilp of the proposal 16,exislingrornmunity facilities vdibch all or serve It,
such as roads, shopping ar.90S, ,Schools., etc, The map shall all sfiowall properties, IdEnfily owners. sUbdivtaTions, streets, and
easiamenft within 600 feet of the properly. Stroh as skelch nl supe6mposed on a,Uirihed5tates Geoloalklal Survoy map of the A -5
area.
The site plan Oall,be drawn at a.scale of forty feet to the Inch (111 mm 40 fasI)cir such ojAer mle as the planning Board may cteam,
appiopriate,on standard 24'x 30'sheats,with confAnuaOnn an 8i4*X I V'shunts as nacwsary for written niormalto. The Wornrl,
listed below sll be shown earn ft s7le,pllan and corolnuation sheets. A-6
C Name of lho,proset,boundaries,date,north arrow,and scale 04 ft plop, l
D Name and address,01 the:ow nen 01 reaurd,developer,ands seal of the enginear.archilect',w,landroapa ardbitect If the applicant Is no
ll record mvnor,a letter of aoftrfzation shall be required Iromr the owner f"q
E rho locatlon and use of ON a4utrng and Proposed stroallures 1w' 1iin Me property,including all dimensions of height and Ifoor atea,all
exterior entrances,,and all antirlipated kitura:additions and alterations. I A-1
F The kcallon of sit present and proposed public and private ways., off-street parWIP9 areas, drwwayg, ouldcar storage aleasv
sidewaft,rampis,cuirbs,paih5r.landscaping,waft,,,and fences, t4caticm,type,wid soraaning daWls for all WaSL-disposal Containare
shall aRsD be shown, A-5
Ther lwalion,height,Inlonsfty,and bulb Zype,(sodilul Incandescen't, M.)d all external Ii Ung lixtwas,. The*006on 101111urninalbn
and mel to eUrninale g;lare onto adjoining properties rnust 91so be shG=in corl vAth§1 79-6,Q2Q. �JA
H The luoelIlqn,,height,size,materialls,and,design of gill proposed%Igns. A
The lCoalian of ali present and proposed ulidlt�systems Including.
ti. Sewage oir septic.,systant;
2, WaI;v;qWp*system-,
3. Telephone,cable,,and electrical syslemis: and
4- Storm drainagas"m inn Audling exisling arvd proposed drat;lines,culveris,catch basEl heal ondvalls.hydrants, P41 A
mantiolas,and dralhage swales.
Plans to prevent the pollfutlDn of suiifface or groundwater. erosion of soil both during and after owstruc6on., 0*00"We runaff, and
flooding of Other propedles, as opl A Stormwalar Polkiftrl Prevenfion, Plan (SWPPP) for all land development WIVEM
(excluding agricultural aoUvIbes) ,an, the site that results In,land disturbance of 1-acre or MM. A 8 gall ODMIJIV with 1he,
MquirarrarrIs of thie MC SPOES MS-4, Geral Formilt and Chl 147 of Vie Tawn of CiLmansbufy Code. It shiall bus at absIlk,
discretions of the Pilanning Board as to whalhar a SVVPPP or an aroslon and control pian shaill be reWred for asite plan review project
tend disturbance ort s then I-acre.
E)dstlmg,and proposed topography at twofoot contour Intervals,or such other corl]Btalrval as the'Planning Board shall allow. An
otavations shall refer to the wrest United States Coastal and Geodetic 8onch Ma& If any portlon of the parcel Is Within 19'10100,
year floodoll the area will be shown,and bare Hood slevationsglven. Areas:shiail be Indicated witin the proposed site and whNn
50 Leet of the proposed site Mieresola removal or 151"t Is,required,showIng the:appl Yokune In ouWc yard,.
L A landscape plan showing EM exisginti natural land features that may Influence the deal of the proposed use Such 00 MCk outcrops,
stands of Imes, siril tress,eight or more Inchas in diamater, forest cower„andwalar sources, and all proposed dhanges to,those
l' lures Including lsizes and typos of p1lonts. Water sources Include ponds, lakes,wetlands and watercourses,aqOrlers,lloodpWins, pix
and drainage retention areas.
MI Loci Use District toundaries Mthlp_500 Jost of:the&U% perimater,shall be drawn and Wenfified on the sRe plan., as well as any
Dmrlay Dlsldthat a"to the ptopeirty.
$11a Man ReVrew Revisi5d March 2014 6
Town of Queeinsbury PlIennIngi Office-7412 Bay Road-Queer bury„ NY 125114-5116-7611-8220
RZOW88MENTS CON1171 N01EED S to ae t
N Traft flow pshems within the slie,entrances,and,Wts,and loading and unloading areas,as well as ouch cuts on tha rile and wvithln
100,feek of the site, The PlarnIng Board may,at.lAs discrelfon,require a datalled Iralfia study kyr la"developm"or for,those in
heavy Iraffla mmas,whloh shall Include,
t. The prc]ected nurniber of molor vOlde,tripe to,enter or leave the site,eslimaled for we6ly and armuel peak hour traffic
favels".
2. The pmlecled traffic flow pattern including velitcular movements. at all major J'aterse0OWS likely to be affecle4l by the
proposed use c4 the site,,
3. The impact Ofthis Iraffic on levelsot use an abutting pUbIle sireets and at affecled intersections. Edsting and proposed
weekl,y and annual peak hour traff la:lovets and road capacity levels shall also,be given,
For new cunstruction or alterations to any McIVIS,a lable conlaining,the 101110Mrig Interrelation Shall be included.
1, 128finatett area of structure to be used for particular pUf PDSNr Such as Jalap riper afian,offic%storage,ate.,
2. Es1knated mwdmum num barof employees;. NIA
3, Maxim=seating capacity,Where aPPIcablial and
A. Number of parking spaces iulsjing end required for 1he interkded use.
P 1, Floor Stam.
2. El�evafiuns at a scale of one-quaftr Inch equals oma fool(1/40=I foolyfor all exterior facades of IN proposed strLicture(s) and/or
aillerabaflu to papslong Df existing facades,showing design features and inftairng the type ands color of malarlinis to be usied,
Q Salt togs,water supply well and percolaMon test results, and storm runoff calculations,as neaded to dletennine and mitigate project
Impacts. A
� Flans fordIsposal of cons:tf uction and demolition waste,aiffier on-alto or at an approved diposal lacility,Plans for snow,removal,indud�ing to of oo-site snow elofage. N
T' An,Environmental Assesment Form CEM,.as requilted by the SE-QRA mgulatione,with Part I completedby the App ant S,ha111 be
submitted as part of Ifie applilraU= If the proposed project requires a special use permit and an EAE has been su brn,tted In
,conjunction Min a special use permit appicaftn,a dupticate,VAr is not required forthe site plan applostlion..
U If an application Is for a parow or parcels:on which rnore than one rise is pfopgueid,the SpOlGant may eubmit a single appiloation foT
all,swsb uses provided the proposed uses are accurate d'aNneated on a site plan,drawn pursuant to Vie roquirments set forth
above, The Planning Board may grant the application W4h respect to some proposed uses and not others. For purposes of reviewing PC
an applkatlon (and for SE RA compilance) all proposed use on a single parcel or, on conliguous pasosis shall be considered
together.
V A lomat narrative stalemient on how the"c;t proposed for review furthers or Is consIslent w4h,the vision,goals and policies In the
Town's Cc mpyebenslue Plank.
SIte,Plan Review resed March 2014
Town of Queensbury P'lanning Ofiftoa-742 Bay Road ,Q�ueensbuiry.NY 12804.518-7614220
Pre-Submission Conference Form r179-4-0401
1. Tax Map IIS
2- Zonlng Classification
fsd
3. Table of:Allowed Uses
'A" is subject to Site Plan FlevWw
4. Ordinance Secrion#
S. Pre-Submission Meeting Notes; Outstanding Items To Be Addressed Include-
d yes No
General Inform—ation complete yes No
SIte IDevelopment If Comp[ete --LL Yes No,
Salback Requirements Complete ye's No,
Addillonial Project Information Complete yes No
!Coveoge,und , DEC SWEEElmom Yes No
FSR,` orksheatcomplete 777�,,Y&B No
Standards addressed t/— Y*,hl No
Checklist Items addressed ya,8, No
m
EnvironentaJ Form compleled ��Yes No
Signature Page completed 7
__je Yes NO
�a
4 a,
...............
j&RUjR=-m= provide gf lea with Notfcgi-QUIWnt(NOD-. SWPIPP hacu=m& rm. DEC lefter nuMhgL
NgJJQLgJ-TqrMhn[atIon (NQ,
Staff Representative. 0 f"
Applicant/Agient
$!to Plan Revs iew RevEsed March 20,14
Tonin or Queensbury Piannhg Offiza-742 Bay Road- Queensbury, NY 12.804 518-761-MO
W20
Appendix B"
Itt trt CH011S for CQFpjetjng
Part 1 a Project Information. The applicant or project sponsor is responsible for time completion of Part 1. Responses
be�ccrrne part of die,application forepproval or fandln&are subject To publk review,and maybe subject to fu Tther verification.
rrmplete hart I based on information currerutl,y ava6lable. If additional research or in esti tion would be needed to fully
respond to any item,phase answer as thoroughly as,possible based on current Information.
Complete all items in Part.L, You may also provide any additional information which you believe ww!ill be needed by or useful
the lead ncy;ottaclu auluiW nlGual pees as necessary to suapplernrent any item.
Tart 1-Project and Sponsor Information
'Marne of Action or Project-,
—T'a�nv SAIC,
Project Location describe,and attach a location map).
15- I-c - 1
Brief"Description of Proposed Actiion.1-
Name of Applicant or Sponsor. 'Telephone, ..� ,.m
L >r" E-Mail: -
Address:
city/pState: Zip Canute-
La Y, N Iq
I.Does time propoeed actio r only i6olve the legislative adoptionof s plan„local law,ordinance,„ NO YES
administrative'.rule,cut`regulation?'
If Yes.aftach a narrative description ofthe inma orthe Proposed pion and the environxnenW, resources that
may be affected hi the municipality and proceed to Part 2. If no,continue:to question 2.
2. Does tlue proposed actionrequire;a permit,approval or funding frormr any other governmentalAgency? NO YE
If Yme lig agfmay s)norne and pe m,it or approval:
3.a."Totalacreage of the site of the proposed actihamn acres
b. Total acreag,e to be physically disturbed? glj�r„ape acreS
C,,Tote acre p;e(project,site and any contiguous properties)m ned 2,O 2,0Or controlled by the applicant or project sponsu aca as
4. Chuck all land uses that occur and adjoining and near the proposed liana.
�a Urban 13 Rural(Don-Agriculture) 01 Industrial orm e ial i�kwidential(suburban)
G Forest EI(A ricultore 0 Aquatic 0 Other(speclfy�w
tt Parkland
`age 1 of
5�. Is the proposed action, N 0 ;Y�ES MA
a.A permitted use under the zoning regulations" X/
b.Consistent with the adopted compreheosive planl?
6. Is the.proposed action consistent with the predominant character of the existing built or natural N0 YES
landscape? 1
T. Is the site of the proposed action located in,or does it adjoin,a state listed Critical Environmental Area? NO YES
1f"!r'es,identiry:
3. as Will the proposed action result in a substantial Increase in traffic above present levels? �NO YES
bm Are pub]to transportation service(s)available at or near the site of the proposed action?
Q Are any pedestrian accommodations or bicyolo 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 1
If The proposed action will exceed nquiremen ts,describe design featum and techoologies:
10, 'Will the proposed arAion connect to an exisdngpublidprivate watersupply? NO YES
If Yes,dD013,the eX i5t:jng:SyStern have capacity to provide service? '0 NO,El YES
If No,describe mothod for providing portable water. V/
11, Will the proposed acdon'U—nnact to existing wastewater udlidos? -�R—O ' YES
IfYes,dbes the existin—system have capacity to provide sery1ce? 0 NO 0 YES,
If No,describe method for providing wastewater treatment:
112, a.Does the site,Contain a structure that is listed,on either the State or Natlon;-1 Register of Historic NO YBS:
Places?
L Is the proposed action located in an archeological sensitive area?
13.a.Does any portiml oftheshe of'the proposed action,or lands adjoining the proposed action.,con, lain NO YES I
wet]ands or other water bodies regulated by a federal,state or local agency? - 7
b.Would the proposed action phy's;la ly aitcrt or encroach into,any existing wetland or waleThcidy? V7--
If Yes,identlfy the wetland or waterbody and extent of alterations in.square feet or acres:
14. Identify the typical habitat types that occur on,or are likely to,be fbundr on the project Site. Check all that apply-
0 Shoreline 13 FaTest 0 Agriculturallgrasslands 13 Early mid-successional
CI Wedand E(Urbian M,Subuiban. -No
15.Does the site of 1he proposed=fion.contain any species of animal,or aaacciated habitats',listed YES
by the Stateor Federal,government as threatened or-endangered?
16.1;;s the project We located In the 100 year flood pWn? NO YES
17,Will the proposed action create storm water discharge,either from point ornon�poirktsources? NO YES,
if Yes,
a-Willstorm water discharges flow to adjacent properties? OINO 13 YES
b. Wil I storm water discharges be directed to,established conveyance systems(run ft"acrd storm drains)?
IfYes,briefly describe. ZINO E3 YES
Page 2 c,F4
nelude construction or oher
Fy1daterear nn ilquidat�e,,�?raterqaarK pond,WMte latg�el�art �garrl�esthat result ion the impoundmentref NYE
es ex
pla;in purlx=and size;
19.Inas the site of the prnpuzed action,or an adjoining proper been lilt location raf'an active or,closed NO YE
solid waste management faallity?
1f Yes,describes
20,Has the site-of the proposed action or an adjoining property been the subject of rernedistion'(9mg0in or N 0 —Y
Completed)for hazardous waste,
1f"des,describe
I
FF' HAT E ,p` ' TjQN PROMED ABOVE ISTRUE AND C 'LVtRATE T THE Lit `1"` :p" Y
ApplliCarat sprnrasanr raatn Lauea
re eDate.
�r
Part 2-Impact Assessment. T'he Lead Agency is resp0rnsilate fuer thee compl<ration or Part 2. Answer all of the following
questions in Part 2 eking,the information contained in part 1 and gather materials submitted by the project sponsor or
otheryVise available to the reviewer. When answering the questions the reviewer should be guided by the concept-Have my
responses been reasonable considering tl'ne,scale:end context:of the proposed action?"
No, Moderate
small to large
Impact impact
nua,y easy
trema• occur
1. WHI the proposed action n create a material conflict with ars adopted land use piaci or acraing
regulatlaar
2. Wil 11110 propubsed auction.result urn,a age in the ime or interaalty of use of lard?
j
3. Will the proM. cd action,impair the character ar quality, of the eltis ng community?
4. Will the proposed action have an impact on the cruvironmentel characteristics that caused the
establishmentota,Critical Environmental Area E L
S. Will oboe proposed action result in an adverse change in the existing level oftraffic or
affect cxistlninfraslTucture bir mass transit,biking or walkway?
6. Will the proposed action cause an increase in the use o.f energy and it foils to incorporate
reasortably availableenem conservation Cr renewable ene,rg,y,opportunities?
7. Wit The proposed action impact existi
a.pubiiic J private water supplies
b.public l prhvare Wastewater treatment utilities?
S. Will the Proposed action,impair the charactercrquality cEimportant historic,a haeclogieal",
architectural or aesthetic resources?' V/
% Wil the proposed action result in are adverse,change to natural resources(e-g,,,wMands.
waterbodies,groundwater,air quality„flora and fauna)?
Pegg,3 of
No,or• Moderate
srn211 to large
impact lrrrpact
may may
occur occur
10. W ii tate,Proposed action result in an increase in the potential dor errsion,iloodin or drainage "
problems
l. mill the Proposed tion create a hazard to environmental resources r r humarn health
Z:I=
Part 3-Determl[ artiort ofsignificance. The Lead Agency is responsible for the comptetion of Fart 3. For ever
question in Fart;2 that was answered moderate tr,-'lerge invpact May occur"li,or if there is a:need to explain why a particular
element of the proposed action may or will not mutt in a significant adverse environmentai impact,please coi Nrt 3.
"art 3 should,in sufficient dull„identify the impact,including,any measutes measuresor design elements:than have been included by
the project sponsor to avoid or reduce impacts. Fart 3 should also explain how the lead agency determined that the impact
MAY car Wilt not be siVifcant.Each potential impact should be assessed considering its setting,pr6babilitty of occurring"
duration,irteversihiiit ,geographic scope and Magnitude. Aliso consider the potential forcirt-term, ,];ong,-term and
cumulative impacts.
Check this box if have determined,baased on the irrfc Iran and analysis above„and any supportingdocam taatioiia„
ru rn resuu9t in one or more potentially large:or sigpi.uficaunt adverse Prrbpacts and an
� Ohre
that ffie propulsed auctio
environmental i hr'act Statement is required
Check this box ifyou have determined,based on the infumnaticai and analysis move,and any supporting docaarnentatio-ii,
that the proposed action will not result in any su,gni,ficrat adverse environmental impacts.
11
Tar! of Uad Agency Date
Title.of Responsible onsible b
print or ii'e Name of laporusih�le Officer in Lead,r�Agency p cr
12 i 1c,�Ir 4
igrraturre.o 1[pesponsible Yucca°in;Lead Agency I Signature of Preparer(if di event fioni Responsible,omcerr)
Page 4 of 4
Signature Page
This page irrdludes the 1.,) Authorization to Act as Agent. Fora: .) Engineering Fee Disclosure, .) Authorizatlion for$lite
Visits; 4.) Other Permit Responsibilities, .) Official Meeting Disclosure and g.) Agreement to provide documentation
required.
L.W N'MR'M N., AIY II '4.PHlm. ' TAW G.+r"N
Complete the folloWirn>,g If the OWNER of the pr'aopeity Is not the same as tura applir a ut
Owner G
Designates:
As agent regarding. Variance Site flan. Subdivision
For Tax Map Inc,. .' aw tion -- Block Lot
Greed Reference- Boob _. ®Page Date
OWNERSIGNATURE: DATE:
APPLICANT'APPLICANT's AGENT FORM
crmplete the folllo ir'ng if the APPLICANT ANT Is unable to attend tate meeting or d 1shes to be represented by snother paw
Owner:
Designates:
As agent regarding: Variance Site Plan SubdivisJon
For Tax Map No.: Section Block Lot
Deed Reference:: -Book, Page Date
AIN'`I NtiNT SIfaNAT,UR'E: DATE,
2.) ENGINEERING Eg URE,., Applications may be referred to,the Town consulting engineer for review of'septic derslgn,,
storm drainage. etc. as determined by the Zoning eur PtannIng Department, 'Pees for engineering review services will be charged
directly;to the applicant. Fees for engineer1bg review will not exceed' 1,000 without notification to th,e applicant.
.) AVITHO I ,&TIGN FOR I . By signing this page and suubrnitting the application owatorials attadhad herein, the Owner,
,!applicant, and IriW'h'er ibetr agent(s) hereby aaulh adze rine Zoning Obard or Planning Board and Towyn Staff to enter The suabject.
properties for the purrpose of reviewing the applinaOon subrnitt-ad.
4.) r 'YFiptt Pr: I5IUTI : Other piarrrnits may tea urequired for construction or alteration activttyr subsequent cent to approval
by the Zoning Board or Planning Board, It Is the,auppllcant's respordsibillliity to Main any addktional perrnils.
5.) Qr-fIQJAL MEETING MINUIlg§Qjg : It is the practice ofthe Community Development Department nt to have a designated
stenographer tape record the prooeedings of meetings resulting frorn appllicatiord, and rnlniutes transcribed fforn those tapas oonsiflutes
the,officlal record of all proceedings.
G OVIDE QCCU ENTATr'ON J3EgLJlRM Ia tho uuindorsig pad, flava thoroughly read and under-stand the
Instrauctlons for submission and agree to the submission requirements, l admowledge no construction aoilvitles shall be comm,ernoad
,prior to Issuance of a valldl permit. I certify that. the applleation, planes and surpporlirng, materials are a truce and complete
staitran'wrtnWaswiption of the existing oonditfons and the work proposed, and that all work wilil be performed In accordance with the,
approved plans and In conformance veins local zoning regula ions, I acknowledge that prior to occopying the f illtles proposed, I or rayl
agents,wUl obtain a c.-erliftale of occupancy as necessary. l also understand that Itwo may be required to provide art as-bualilt survey by
a Ik2,ansad land surveyor of all newly consmicted facilities pdor to issuance of a certificate of occupancy
I have read and agree to the above.
Signature[ ppli t] Name [Applicant) Date ignik
Signature[Agent] Print,Name [Agent] fate signed
_
Site Plan Review Revised March 20,14
Town of Qureensbuuy Planning Office-742 Says Road Queensbury,NY 128,,04.518,761-822