Site Plan Application ENVIRONMENTAL IC ESIGIN
PARTHIP,LLP
January 1 , 2017
Town of Queensbury Planning Board
742 Bay Road
Queensbury,NY 12804
ttn: StephenTraver, Chairman
Ike: LaFleolue Residence - Footers Edge Drive
Dear Steve:
ubmitted for yo ur review and distribution are 15 sets of Site Ilan Review application
documents for the referenced �arojeet. Included are the application, Site Plans, architectural :floor
plans and elevations., a boundary survey and deed, .variance application haus leen submitted
to the ZBA seeking relief for the expansion nsionnof lawful nonconforming in stmeture® Wastewater
system compliance will be satisfied through the installation and use of au holding tank system
approved by the Queensbury Board of Health (approval resolution attached). please refer to the
attached project description(Sheet -1)for ftulher detail of the project.
eet.
By copy of this letter we request an waiver for submittal of several items listed as part of the
application documents.
• A waiver is requested for provisions detailing handicapped access and parking, loaidi:n ,
areas, signage , lighting and multiple use area breakdowns.
Thank you for your consideration of this application and I look forward to meeting with the
Board for recommendation and review at a January meeting.
Sincerely,
C-��nnis MaclElroy,PE r'
Environmental Design Partnership
JAN 1 20V U4115
Attachments
Cc- Steve ryn L all�leehe �, � �f ICE,. ,
900 Route 1416. Clifton Park, Niew'York 12065 phone (5 18)371-7621 fax( 18)371-9540
SIW Plan Review'Revised June 2009
General InIl'brmation
Tax IR reel IU: 2.7„17 .- 1I -29
Zoning District-; WR
Current Use, single,famfly residential
Proposed Use: Single family residential
Location of project�: 12 Waters IEdge OrNe off SGall Load
Applicant Mame Stephen & Caryn LaReche Address: T2 Berkshire Drive Clliften Perk,NY' 12065
Home Phoria I Celt
Work Phone Fax
—f-wir.................
step herilaflechie@gmail co,m
Agent's Name, Dennis Mac:Elroy Address:
Horne Phone 792-182,010 Celi, 5118 376448,5
i Work Phone Fax
7611-0317 761-0371
E-mail dmaceiroy@e!d'plipi.com
Owner's Name: same as applicant Addresr,
Home Phone Cell
Wo,Tk Py re Fax
E-mail
Town of'Queso.9buy Planning OfFice-742 Bay Road ,Queeinsbury.NY 1284.518-751--8221 2
Sine;Plan Review Revised,June 2000,
Site Developfflgnt Data
Area I Type Existing sq.f. Proposed Total sq.ft.
Addition .ft.
A. Building footprint 2362 0 2362
B. Detach d Garage i
C. Accessory Structure(s), 0
0. Paved, gravel or Other lardsuTfaced area 2368 (-120) 2248, .
191 191
G, Total Non-Permeable [,add - D
X921. (-1, u], 48011
. .Part Area [43,560 sqft. )acrej 8276 8276 i 8276
[. Percentage,of Im7ump rrrueab[e Area af Site []=G/H] 59.5 % x4.5 % 58.0 `X
Setback Regi r ment
Area Required Existing Proposed
Front[1] 0
Front[2]
Shoreline 510 19.6 19.6 (29.5)
Id'a "hard;[i] 15 47 (E) 4.7 ('d.1) (IE),
Gd Mrd [ ] 11 91.4 ( ) 4 (W)
Rear Yard`[1] 30i
Rear Yard [ ] 30
TravaJ CorrIdor NA
1
.,
parking spaces
Town of Queensbury,mannIng Of fi .742 Day Road•Queembury, NiY '1 0104, 518-701-8220
Site Plan Raview Revised lune 2DQ9
Addlifional Projeqt Information
1 Will'the proposal require a Septic'Vartance from the Town Board of Health? Yes 12-5-16,
2. If the p*cel has previous approvals, list applloafion number(s)., BAH -1;105- 140 --
3. Doles this project require coverage u'ndleT the NYS DEC Stormwater Pollution Prevention Program?
no,
4stimated project.duration, Start Date Mar,"17 End Ctte, June 17
S. EstImated total cost of project $75,000
6. Total area of land dfstUrbiance for project ,I'01010' sf
.Floor Area Ratio Wolrkshe:et
FLOOR AREA RATIO (FAR)--The relattonship of building SIZe to 10t SlZe,derived by dividing tare total buildingi
floor area by the Not size In square feet, y1elding a percentage,
,Zoning DI'Strict Symbol Floor Area Ratio[FAR]
Wat,ar-front Residential W!R 0.22
Commercial Moderate CM
Commercial Intensive a 0-3
A. The combined area of all square foctage, as rneasure from, exterior waWs of all,structures on the property, Inchicomg,all
nobM of the structures, garages, basements and a,ttics, with more than five � .) fast of calling helght and covered
porches. Building aquarei footage does not includbOpen, dleck, docks and that portlon of covered docks e�dendlng
over water and one storage shed of one hundred 'twenty (1 0) squarefeet or less. A,ray. additional sheds will ba
Included. (See'FLOORAREA RATIV).
R Connm=lol or Industrial,the total area In squam feet as m,easured from the exterior,of the out6lde walls of a building
,or structure,,and when appIltable,the surn total of,all floor areas of the prIncipal and accessory buildings or SIFuctures,
on the:project,site,
Parcel Area 8276 sq.ft„
Existing F'1001r Area Oi6;8 sq. ft. [see above defirillion]
Proposed Additional Floor Area -211 $9. ft.
Proposed Total Floor Area, 3059 sg-ft.
katalAllowable Floor Area 1821 (Araa, oa see above ta�ble .
T of,Queenebury Plaflning Office- 742 aay Road-Queen!sbury'.NY 128014,1518-761-820 4
Site Plan Review Revised June 2009
§179-9-060 Reatfiregril for Site Plan Appro 'The,Planning Board shall M appmve� Site Plan unitess it
first defermines thal such site ptan meets OEF Mowing Standards. Please,pplare responses to each of the f0flowMg
foll
A. Titre proposed project furthers or is consislIerl withi the pdldes,of the Towl Comp
E, Til proposed pro jMcicarripiles Will all othat ws udtsmerals of Ihis Chapter,IndudAng the sille plan review stendards as set forth In Paragraph F
of this sedlbnw the,dkniell,l and denallity regLiations of the zoning dfairil In il A Is proposed to be located(Iil$and Table 1).,
the ap
,l
SJl well
111"==
C. The sills plan encourages Wastrian,aclill Internally and,,If practicable,to andl fmmi the aIle With padesirfan plaft cr"lilidevilea-con"ne-cled to
adjaioant areas.
Ex Tbe site plain must conform to Chapitar 11.16 tal and Sil Disposal, Chapter 147 SIGMUFMa r Wnegament IL"alWLarww, and other
appRueble local law% 'l I
E. the proposed usashy all be M harmlolny'vAh[lie gonorl purpose or hient of ibis Chapter.spedfIceAV laking Into,accourill The locallon,Character
and size of the proposedi use and the description and'purrpose oflr the disIdut In wilhichisuch use Is proposed,the:inature and[ill enialty of the
activIlliss to be linvolvael tin or lcor4uct*d to cooril Will IM proposed use and the,rmilure andl Tate of any Increaw In the burden an
supporgrig public seliMices:and faclIffies%l Will Mow rhe aplTroval of the piropiomd use.
IF. The:ostablishril mainjansinea and oparallon elf the ploposed use will not createpubto liazards from lraft i[Taffic congeaton or the parking
of vehicles andlor equipmerA or be otheirvAse detrimental to the health, safety or general MIRAM, of persons rissildN of wl In the
neloh4whl or to iha general wel of the tol Tieft access and dredation,road Intersections, road and dr[yel widihs,andiraffilm
controls Wil be adequal
G. Off-treat parking and leading fadiflas Wit be approlorlatally located,and arranged and sulfiklent to meel traffic antlicIpated to be generated by
the new use. "the estaNsliment of vehicle links bleMeen parking areas of ad]oil p(oparIltes ara proililded whers feasilblo, 'Trills fuildhers the
Tomi's goal ofreducling curb cuts and reducing congeallon. A,twenty-foot Wde connection IsmiquIred. If 4al propertles are alliher
undeveloped or previllously developed Mhout hall made provision forfulure linkage, than a: l comecAlion must ba lelerillified and
pinvDded fbr in the she plan Lmider revil for rulch futwe finkage whan 1ho ll arises. The Plandirg 9oardt may rejulre proof 1hat Me
appticant has made corl Yl adjacent property opmers for purtmes,of owdInalliniq llr*agea WAh adjacent pyoparilas.
K The prollsel.shell nat hava an undua ail impact upon the rl rearifc,aesihatle,ecological.,wildlIfe.blisill reirielaftnall or open space
resources of the town or lyre Adirondack Plark or upm the adequate proWsion of supporting factlires condi se:MDas made riecaisa$ry by the
projecl,taking into,all,l,1110 oorriurr4ar,clal, Industrial roldanul,,racreallonat or odder benefits that ml at be derived ftorn,the prop t: In
making the deleimilniatton hereLmder, the Plarming Board shall consider those Wors pertinent to,the pr*ot emlabied In il devetopment
cansiderailloris so.(wM hal under§ 179-9-M of ll cilepitar,and Iin so dating,the Planning Board shall mid l a riat QVDMK ovalualM of
the proles In relalion to Hie development obfil and general 9uk$e§fle5,5eI:forilhi In 6 1170-9-�080,offil "l
1. The provi'sillan for and arrangernaril otiparlastrian tralffir,access and drcuitaillan.vl Btrurtures,control of itntamoclonla v vehicular lll
and overall pedestrian convenlarl shall)be safe and adequate for 1pedestriiaini movernerilL Fledoetriarl connWilons baKl adjacarit shill
shall be$xowidad lie arentiral padestrian use.
J. Stounwater drainage acillItles,^wdll prevent an Inualase of post developlal draInagv l as carr) Gad to ford-dowdopolil dralinage ll
Dralriall the alto shisit ra"atole gtowrild water to the eAent piaclIcat, Surface waters Awl off-sIlathaill snot degrade any s1raerns or
adverselyall drainage cin adjacent properties or l roads. Facilities shall!ba In conformonlile il 010 dirolnehe standards of Chapter
147 Ofthe Town Cold)8414 The ToYM of Quorl$A0100orl Ragulall Whard applicable. *yll
K. The water,supply,and sawage d1sposelfaellffies Will ba adequale and vAl meetall i0mc-a-b—le-a-M ctuneri-requIrementa set fell by Depanniliani
orf Health rehulaltonsand Chapter 1 nof the Tol Coda, *-1
L The 4" old arTanoarneril of treau.,s(bril yard other rwlilable plarfings,landsoopling and sorl all effedtil pMVjdj j-
v1sual and/or nalse buiffe!ir betmel the applicants all adfolrill Ilands, Including lbe mmOnrl mleollon, of sodsHnio vegFAlation and
malintenaince,inctil replacement of dead or de cased planta„ -1
M. Fire lanes,emeigem zones,and life hydliall YA111 be adequate and rniselthe needs and rap rainenta ofemaill senice providers. t4A,
N. The:des gin of Mcivill irodl y,s and landsQepdq[In,afeas suscapil to pending,,,floodini indfor erosion,WRI rnlnkr�lza or avold such
lrnpalcts to the maximum exterit pradlcabLa.
0 --Tfie$140 plan,rorforrins to The deelgo standards,Iandscalolng st r4ards and performance sUndardsnj this diapter.
Town of QiUleansbury Flalining Off cal'742 Bay Road'-Queensbury,NY 12,804 - 518-70"220, 51
Site Flan ReVrgew Revised June 2009
1794-030,ARpIll for Sl Plan Review
Application for silts planapproval shall be made to the Planning Board using Firms suppliedby the Roard,Application rnaterlbgs and the
alte plan shaW inoluud'e sufficient iinrorrntation f'ar the hoard to make Its tidings ander§ 1701-9-070 and 179-9hell. In detarrmni
the content of the site plan and suu,ppil documnentallon than Planl Board may,waive ceiWni requuirennnionts If'the Planning'Board
deems such requulrerttente or,I nforrruetfrmn unne awry for the tape of pro)el proposed. Any such mwu'aliver shall be arcade fru writing,and
shall contain statarnents of the,reasol the walwedl lrirmalllon requirements are not necessary for an Informied rel under the
ofrouurmstances, The Planning Board)May grant such waivers on its e rt lnilleAve or at the i request of an aupplicant., Such reoi,urpst
slum set forth the specific reguuliremenfe that arra requested to buy"wwralivad and the reasons for the requested wrralw^er; Absent any walarer
or wagvers,aura appl'gcatlon For Site Plan Rehew shall lndude the fldllolill
Shown
REQUIREMENTS (s,rru sheet
wloinIty map dlraml at the scats that A�huom til relationship of the proposal to eads'png community faoldllas rov W)affect cr serve,It,
such as roau , abol areae„oohoole„ et'o,. This maga shall also show all,properties„Identify wrners, subdl agcrros, sireels, and -11
easeooirenie Within 500 Feet of the property. �5uaoh a sHelcb may be superimposed on a United States geological Survey"map of tha
area,
pia p' shoals,rt Ma oontlnu�allran Ion a feel I, she Ns necessary for�mmurtHt g inform many rhe ho
Thee s5a plea shad be oral at a scale -�
I e ma date„ �� atdard '�' ,� ��� - � � "" en Hrnfcrnroatlon. e
informal listed b o w shalt be shoe on the site polan and continuation stream.
► acme w# e r � �s IsaLmdl'arlea,data,north er
p � "' ,-�,,,` �,, , r+rr, rm�t soils of the pian. -1
Name and address of the ower of reu^ordw dew Ioper",and seat of the eni erohil or landscape arohdtect. If Hhe apfill' nt'la 1
not tha reecord owner,a Netter of authaarizaulon shall be required from the cwimuar
' ;The location and use of all eslsUng and pri strudiures Within Me propel,Inolucilmgl alt dlmmensfons of befght and'Boor was, OM f �
extedur entranoas„and ail arrt'tddpaled future addlticns and alle dons,
The location of a �,. . .
� ll an pry n�H and prop+�e�d purhll and pirate wrays, odG•street parlift areas„ drlwewys„ ouuido 'storage ara., I
s4d1rrelllXl''j, raMl Cuarb$. pi i, lands w,nahs„ d fames, p ocall ". and acraemmlog datells for&ti waste disposal -1, -2
o antalners shalt also tae sho'wn,.
The lol hiatguht,irwtesrratly,and burg type incandescent,(al etc.)of all eadernall Ifghling ff nares. `rhe ddreti on or IHlumminat rro -�
aid nmaihods Ito,ailmluate glare cM adjoining poopartlas must also be shown complianceIX117 f-i
The tocallon,height.slue,materials,and all of all proplamdl signs, lh A
I
The focatlan of,all,presera and proposed)urliltysy^ster s,Including-. 111 -2.
.„
I. Sevagie or septic system,
2. WataTsupoly syrti i-3,
. Telephone,,cable,and electrical cyst uro"st and
4. slate dlratnap system inciudinh erwlstiump and prop«osedi doralin Mines, culli cetdh basins„heedwrallls,andmft, hdral
nnandhoHea anddratnadez'aaafes.
i
I plana for Prevent tine polta,itdon of surface or groundwaater” arcemlcon of loll both dumiRgit and after oormatmidtfoo, a milm runoff, and
flooft of other properties, as appiloall A Slicamater Pollution Preanerd on Plan (sVVFFP')for ad land development advU s
(eauclodl g agr'leoltturell insoles) on,the efts that rasulls In,tamdl disturbance of 1-awe or mi A'SMP shall conte r vift the -„p
regVrametite of via DM Sill ll Ganarad parlirrifi and Chapter 147 of the Tom of Queo mslhury Code. It.$haul be aI,the
disomllonr of ftae Fiainni Board as to"ettreiaM a F3uvw,rpl or an erosion and control plan short be required Fora site plan review project
land disturbance of loss Hban t-al
K
a -
f rlatlnp andproposed topogoraphy at tufo-foal cohtOur Interwar,or such other contouar lntanial as the Planning Board shell agar. AN
0404400%shad refer to the nr camel untteut Star as Coastal and Gecdeli ranch Mark. if any portion of the parcel Is wwt'galn the 1100- -1„ -2
'Year floadplaln,the area VIII be shownand,barm flood elevations gil Ams sh l be Imdloal Within the proposed site and vi
5l11 Not of the proposed site where solC removal or HllIng Is required.s'hol Hlwe apfa'r'o'adimata vi In cubic yards.
L A iondscapo piton bhowwdnq ag aadatingl natural land foatuurea that;may frifluence the del of the proposed use such as rock,ortotcrdapsd
,stand's of trains,stnde trams ethill ar more Inches tiro diameter,forest rijill,And water'ears,and all proposedl changes to,these S-1
features'InciudHi'np rhes and Was of ptaanis Water sources.(Include ponds,laker,,vmftnds and'wratercoa'urse%axltilfera,flVoo pta1ina,
and drahnayge retention areas„
M1 Lend Use Distact boundawies vAl 500 feel of the sil perimeter shall be drawn and identglerdl on the site Adan, as VM11 as any -fl .
weds Msgriicls that apply to the pru artyr.
'Town ofOusensbury Planning Of lce°742 Stay Road �Queensbuiry,NY 12804 -5118-761-8220 6
Site Man Review Revised June 2009
N Trafflo flow patterns Wth1h 010 slto,enlrances aind oxils,and loading and untoadingi ama,as Ymill as curb cuts on the site and Within
1,00 Feet of The alke, The:PlannIng aoard may,at lir d1sictiallon,require a cletaflad Ifaffic study for targa davatopments or Fpr thoii In
he +y trafio areas,uAlicil sliall Iniclude-
1,, Tba projected numbu of motor vehicle Imps to artier of 1080 the silo;,sslknated for weekly and annual peak bolur traft
favels,"
.2�. The projected traffic flow pattern IncWdliniq%vblidplar movements at all mai Interseclons Wely to be, offsowd by the
proposed use inP the site,,
a. The lOnpad of this Iraffm on levels of service on,sibutiling pubilc streels,and at affected Inierowforls.. Existing and proposeci
weekly and annual peak hear trafflc,levels and mad capaielly levels shall also be,91ven.
0 For nerw consbrucdon or a4leratians to any slrur.Wira,a WN,containing the folbi Inforni all be,IncWdad, NA
I EvVirraled ame of s0uclura 10 be,used for particular purposes such as retell oporailonf,016ra,,sloi etc.';
2 rUakin0aid maximum nu ober of emploi
S. MwArnuirn seating capacity,Where,appi arW1
4,. Numbler of pa*lno spsegm akfaflino and required for the Intended usa,
P 1. Floci, attached
2. ElevaiIInnt at a scala of one-quader Fnch equals,ona fool(114"�I Out)for all exterior facades Of the pfuplosed 11tFUCIUM(S)Ondlof
allerai W or expanslons of axls;lng facades.showing desfqni featUres end!WbOtIng 1110 type,and color of materials to�evsodi.
SgM toosi,wolei supply vmtl'and percolation lost results, and storm noff as needed to delermline and ffftal;tt project NA
Impacts.
R pliana Or disposal of iconslmdkm and demoUGn waste,either on alto or at arr opprand disposal facIlIty.
Mans for sraw removal,Inidudling bicallonfe)of w,slta znow sloraga,
T Ani rtrMironmentsif Assessni Faun `EAF%i reqii by the SEQI�3A regdaSons.with Pad I complailed the AppdIcant shall be
submililed as, plart, of the applics4larp, If the proposed PrOje'dr raquili a speclet use permit and arm EAF has been,sdbmftted If' NA
canjjncflon Wlhi a spout use:pefm4t appftorlon,a dupiftaita r-JT Is not,required for The site plan appftslion-
11:an appOwMan Is for a parcel W pw(*Is on%Welj�more than use Isproposed,the appillii miay r uUmll a single appRicaflon,for
all ZLMh Uses pfavided:the proposal Uses are accurately delineated on ai plan drawm purauant to the ieqLArernents,set forli
a,bDve., The Plarrodnig awd may,1�rai th�a application Wthi respect to sionle pimplaWd iigasacrdarkat others. For purposes of A
r ing an, appigbation (and for 9WRA compIlance) ad proposed, Uses on a sinala parciat or,an conitIguous parcels shall be:
considered togalhar.
V A brief mon alWa slalwrorA on,how O'ia project proposed for ieview fixthem or Is consistent vidlh,Ina%Wori lloals and pofidles in the
i Compiiahanslive PlIan. affached
T
Tom or Queensliblury Planning Office-7428ay Road-Queensbury, NY 12,804 618-761-8220
N
Site Plan IReview Revised June 2009,
Pre-Su hmJssjQqp onfer nce.Fwee F1 -4.0401,,
't. Tax Maps Its 227A7. 1 _29
. Zoning Vassificntion WR.
3. Code Reference for Review: c t
4 Ordinance Keefe rsc�a M III:
?
6, Pre- nbmpsslon Meeting Notes,Outstanding Items
Deed Yep 'o
' mel!Information complete Yes _ _No
Site Development Data Complete, Yes � to
Setback Requirements Complete y'e's
Additional'Prqect InformatTon Complete Yes No
Toverage undw DEC WPPP l?- ra 'des No
FAR t eet complete Yes _No
Standards addressed _Yes "hoc I
011ackfistitums addressed Yes No,
igneture'Page rompri ted "des No,
*�
'Lea ,
` 1° t ,„�, C• pfd s ' ,
l
ray(
e C '40
s
n
n piicantuet r ,t, s „ e
Notice of Terminatugr-M 'T1
Staff Repr entati e,, r
Applicant/Agent. :.
P
Geta. � k
1"e re,of Quaensburu Plan,npng Office-x"42 Bear Bout.Qceenabury,,NY 12804°61 B-761 82,2,0
Signature Page
This qbge jr1cludes the T.)Auffiarization to Act as Agent Form-11 2.) Engineering Fee Disclosore, .) Authorization fbr Site
Visits,- 4.) Other, hermit ROSPOVISibilitles; 6) Official Meeting Discki sure and' 6.) Agreement to provide diocurnentation
OWNEWS AGE't4T FORM�
Complete the fOlowing if the OWNER of the property Is not tate same as the applicant
ovvner;
Designates'.
As agent regarding; Variance Site Plan Subdivision
For Tax Map W- Section Block Lot
Dead Reference! Book Page Date
OWNER SIGNATURE: DATE.'
APPLICANT's AGE NIT FORM,;
Complete the follcpMng K the APPLICAK;T is unable to attend the meeUnq or wishe,5 to be re resented by another party:
Owner, Stcpherl Loplechc
Designates: Denoi� ,Malc Elroy
As agent regarding: X Variance Y, S40 Plan Subdivision
For Tax Refer
DiaMaep n 9' Book No.: 22T17Section I Block 29 Lot
1 87� 'I Page 70-13 Date
led
OWNER SIGNATURE, EATS
2.1 ENGEN99B&a �ttRt=m Applications may be, referred to the Tn consofting engineer for review of "ptic desigrD.
storm drainage, etc. as detairnined by the Zoning or Phoning Department: Feas for engneenng review services will De. charged
directly tothe applicant, Fees for enginaa6nq review will not excaal$11,000 without notifir-at ion tolhe apDlicarv..
AUTHORIZATION FQR SITE VISJTSBy signing ng this page and,skjbrni'fting Ine application,matofi als attached herein, the Owner,
Applicant, and hi herftheir argent(() hereby authorize tkoe Zoning Board or Manning Board and. Town Staff, to enter the subject
propeaiQs for,the purpose of review img thle application,submitted
911HPERMIT R'ESP
0$01LITIES. 01her permits may be required for construction or alteration activity sub&equenl 110 approval
by thile Zoning Board or Planning Soard. ft is rhe applicant's responsibility to obtain any additional permits,
It is,the pr@chce of the Community Development DepairtMent to have a designated
, , FICIA
sienogirapher�ape record the proceedinqz of meefings resufting from awlicaWn, ams minurtes trairiscribeid from those types Comjstjtutes
ffie official recor�d of all proceedings.
6.1, AGREEMENT,TL) PROWDE D0CUM1ENTAT1QN_RKg2!Egp: I the undeirsiqn,W, have thoroughly read and understand the
instri,potions for submission and agree to the Wbipission requirements, 11 ackmwfedge no construction or-Svit$es s1haff baDmmonced
$xi:ior to issuaTme of a valid parmit I certify th!Ept the applicalion, plans and supporting materials are true and complete
statement/descriotion of the existing condidws and the w&K proposed, and that all work vAI'l be performed in accordance: vAth the
approveO,plans and in conformance%vith locai,zoning regulations. I acknovoledgethat prior to occupying the facififies proposed, [or my
agents,%ill 6btafil a Certificate of occupancy as necessary. I also understand that Vvve miay be required to provide an as-built survey by
a licensed land surveyorof all newly constructed faciliffies,prior to issuance ofigi Gertificate&owupancy
t
agree 1 id e. o the above
I have reagllan
yy
nature 'Applic Print N�a�me ,Apph,cahtl Date signed
Uennis NlacL FDV
kt% It- V7
IiS' 5teure [Agenq Print Name [Agent] Date signed
9