Site Plan Application x
'OWN OF QUEENSBURY
Site Plan Review Applicatio�n MAR t 5
Review Process,:
1., Required d 'P` -submissi n meeting with staff to determine neral completeness to be held go lair than 1I
y°eek_yrior io deadline-day Ca111 ( 19) 761-8265 or( ) 1-1220 for an,appointment.
. Submittal of complete application: l original and 14 copies ofthe application package by monthly deadline.
. Det=ination of application completeness, All necessary inf rm tin must be provided and appropriate
fee(s)paid for consideration for placement nt on an agenda r that month.
i
. Incomplete ,applications will not be consideread, for placement on any agenda until all missing
im,farmagy_u has been submitted.
. Submittal to ""barren County plarmmng, if applicable.
fir. Pl 'ng Board meting, generally the third & fourth Tuesday of each month. You will be advised in
writirng as to which.meeting to attend,
7. Following the meeting you will be provided with a c6py of the resolution stating the Board's vision on
your application. 1f your application was approved, the next likely step is a Building permit- Final.
drawings must be provided for the next phase of review. If your,application was denied, your project cannot
proceed as submitted,
DOCUMENTATION REOUMEMIENTS (hard cop
Please submit 1 21ngin l 14 copies ofthe completed application package to include:
Completed Applicat un ,ages 2-9, signed&dated
a. Pre-Submission Meeting Not signed by staff,
Cony of Deed
Checklist & Plot flan
Environmen al Assessment Form for any non-residential project
Fee: 100 — 10,000sq., ft.); $250 (10,001. - 30,000sq. ft.); $500 (30,001 -100,000, sq. ft-); St,ODO
Staff Contact Information:
Craig Brown, Zoning Administrator crai meensbur.net
Laura Moore, Land Use Planner hnoore rneenshu: .nm
Sunny Sweet, Office Specialist—Planning m n inn ueensbnn .net (518) 761-8lM
`isit our website at ww.ammeermshum *.mnet fon'further information and forms
1
Site Plan Review application—Revised.October 2016
Town of Queensbury Planning fflee-742.tray Road,Queensbury,N''Y 1 I3t
General Information
Tax Parcel ID Nuinbev
1 5 2(1`17
,Zoning Digtri ct: Q,k�'�� J fl""
� IJEEFGA
�D
A'I
Lot size: S
Detailed Description of Project [includes current&pro:posUse]:
-aye— 7�t
..............
Location of project,
Applicant Name: Address:
Home Phone 90 eel Cell:
Work Phone Fax 7V-
E�Mail:
A�0110�11-4100wk Celli,
Agent's Name: Address:
Home phone Cell-
Work Phone Fax
E-mail
Owner's Name See 6 40ye, Address
Home Phone Cell
Work Phone Fax
E-mail
2
Site�Plan Review application—Revised October 20 16
Town of Quawsbury Planning Office-742 Bay Road,Queensbury,NY 12804
Site Development Data
Area /T e xisting seq. ft. P'r po ed Tbt l sq. t`t„
Addition sq. ft.
A. Building footprint
Dan
. tache Coare e mm
Accessory Strueaure(s)
D. Paved,gravel or other hard)surficed areaZ L11
E Porches/Deck
G. Total Non-Permeable (Add -F] p '0
H. Parcel Area. [43,5 60,sq.ft.1acre) �
1.. Percentage ofImpermeable Area of Site []� J1°1.
Setback Requirements
Area Required
l�xisting �"r�wta�r�e,
Front [1] 7 q3. " o
Frrajit [
henmelarre ,
Side Yard, [I
Sade"hard [ ]!
l ar Yard [1]
Rear Yard [2]
T1 ravel Corridor
Height [rnax]
I Ll
Permeability
- 49
3
Site l'leru Review applleefilcn- .evused Octobt,-r'210,1
'Town of Queenbury Planning lee-74 �Bay load,Q u oeu bury,NY 12804
Additional,Proiect Information
1. Will the proposal require a Septic Variance from the'l' Board of Health? A�d
I If the p=el has previous approvals, list application number(�):
3. Does this project require coverage under the New York State:Pollutant Discharge Elimination System
(SPDE, S)Permit Program?
4. Estimated project duration: Start Date �0 baudlate -9/ih
51. Estimated,total cost of project: /,5
6
6. Total area of land disturbance for project:
Floor Are:a Ratio Worksheet
FLOOR AREA RAT10 (FAR) -- The relationship of building size to lot size, derived bdividing the total,
building floor area by the lot size in square feet,yielding a percentage.
Zoning District Symbol Floor Area Ratio [FAR]
Waterfront Residential WR 0.22
Commercial moderate/Intensive CMJ 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) ftet of ceiling
.height and covered porches. Building squarefootage 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 ",FLO�OR AREA RATIO").
B. Commercial or industrial: the total area in square fed as,measured from.the exterior of the outside!walls,of a
'building or structure, and, when applicable, the stun total off" all floor areas of the principal and, accessory
buildings or structures on the project site.
A. Parcel Area sq. ft.
B. el sq. ft. [sce above definition
C Proposed Additional Floor Area
-P—. —PERPTO-Sed Total Floor Area I
Lld C ff. A)61 sq. ft.
E. Total Allowable Floor Area (Are,a,x 3 [,see above table
*If D is larger than E. a-variance:or revisions to,your,plan may be needed. Consult with Staff.,
4
Site Plain,Review application-Revised October 20,1 6,
Town,of Queensbury Planning Of 1Bay Road,,Queensbiary,NY 12804
§ 179-9-080 Requirements for Site Plan A12113roval.
The Plaming, Board, shall �ot approve a, Site Plan unless it first determinethat such site plan meets, th.e
following Standards. Please prepare responses to each of the following topics,�:,
C�
Olt CU �tsfx)eqs6
............
STANDARDS
A. The pro
ro�posed pro
roject furthers or is consistent with the policies of the Town's Comprehensive Plan,B. he posed ject,complies withall other requiremerits of this.Chapter,including:(Ke site plan review standards as set forth in Paragrapii
F ofthis section,the dimensional bulk and density regulations of the zoning district in which it ' proposed.to,be located(Article 3 and
Table:I), the:applicable requirements of aft other Articles that apply. Is
eelleelp
T—, an no 4"e's pedes" bile,to and from die site with pedestrian Paths or sidewalks connected-
"he site Our
t d, 'cr"a 6
o ar 11 rus --
it,-pla. t conform to C ...........
D. �
the
osal,Chapter,1478torrnwater Management Local Law, and other
,ppl.
e
,Joe I laws,
,aEbIaE
The proposed use shall lie in harmony with the general purpose or intent—0f th is Chapter,specifically taking into account the location,
cbaracter and size of tile proposed use and the description and Purpose:of the district in which such use is proposed,the nature and intensity
of the activities to be involved in or conducted in connection with the proposed use andthe nature and ra ofany increase in the burden on
supporting public services and facilities which wil I follow the approval,of the proposed use. Xle,,T.
F'. The,eslablishrnent„maintenance and operation of the proposed use will not create:p 11 ublic hazards,from traffib,traffic congestion or the
parking,of vehicles andforequipment or be other.wisc dictrimental to the health,Saky 017,8MOTal welfare of persons residinig or working in
the neighborhood or to the general,welfare of the town. Traffic access and circulation,road intersections,road and driveway widths and
trafrip controls will,be adequate, , e 'ect
511-stTed—parkin and 19toading facilities wilt beappropTiately located and arranged and sufficient to meet traffic anlicipetted to be generated
by the new use. The establishment of vehicle links between parking areas of adjacent Properties am provided where feasible, This fitirtheri
the Town's goal of reducing:curb cuts and reducing congestion. A twenty-Foot wide connection is required., if adjacent properties are either
undeveloped or Previously developed without having made provision for future I inkage,then.a future connection must be identifled and
provided for in the site:plan under review for such future linkage when the time arises. The Planning Board may require proof Oat the
applicant lifts made contact with adjacent property owners for purposes of coordinating linkages with adjacent properties,
H. The project.shall not have an undue adverse impact upon,the natural,scenic,aesthetic,ecological,wildlife,historic,recreatiortat or ope
space reSIDUMCS Of the town Or the Adirondack Part or upon the adequate pm. ishan of supporting Mlitlf--5 and services;made necessaryilay
the project,taking into account the Commercial,industrial:,residential,recreational Or other benefits that might,be derived from the:project.
In making tbe determination hereunder,the Planning Board shall consider those factors pertinent to the project contained in the
developintent considerations set fOrdi herein under§ 1179-9-0190 of this Chapter,and in so doing,the Planning Board shal I makea net over,a
evalitation oft e project in relation to the deveJopinerit objectives and general.guidelines s�et forth in�§ 179,-9-090,of this Article, 10
The provision for and arrangement of pedestrian traffic access land circulation,, walkway structures,concrol of intersections:with vehicular
traffic and overall pedestrian,coin venicnce shall be safe and adequate or pe tria
, I n movement- Pedestrian connectio is between,adjacent
sites shall be provided to encourage pedestrian use- U1�14, I
� r_-edmko-4�q i v,,Aal ,
J. Slormwater drainage facilities will prevent an increase of post development drainage flows as compared to pare--d-evc-lopment drainage flows.
Drainage of the site shall redtarge ground water to the extent practical. Surface waters flowing off-site", I not degrade any streams or
adversely affect drainage on adjacent properties or public roads. Facilities shall be in confonmance with the drainage standards ofChapter,
147 of'the Town Code and the Townof Queensbury Subdivision Regulations where applicable.
K
e -adequate and will meet alt appi icablc and current requirements set forth by, The water supply and sewage disposal facilities will be 6�i
Department of Health regulations and Chapittr 13,6 of the Town Code. cefre�t
L. he adequacy,type and arrangement of trtes,shrubs and other suitable p1milings,landscaping and screening shall Offcoti vely provide a
vi sual andlo�r noise buMr between the applicants and adjoining lands, includin)the 7ximum retention of existing vegetation and
inaintenaace,including replacement of dead or deceased plants.,
Fire lanes,emergency zones and fire hydrants wil I be adequate,and meet the need's and rcq r uiremerits,of emergency service pr videos,,
Theirnpacts desito the maximum extenta,roadwpracticablys and landscaping,in areas susceptible to panding.floodi—As ancuor erosiw
on ill minliniza or avoid such
e.
0. The site plan conf6mis to the design standards',landscaping standards and tr-ffbirm,�n e st; rds of is ap..ter.
5
Site Plan Rovii application-Revised October 2016,
Town of Queensbury Planning Office-742 Bay Road,Queensbury,NY 12804
1794450 Chocklist-Appili cation for Site lel an ,Review.
Application materials and site plan sl ll include sufficient information for the Board to review and provide a
decision. The applicant is to provide a site plan drawing and all, attachments that address items A-V. Tl
applicant may renae st a,waiver front AN and is to provide reasons for waiver(s)requested. Please label
information to be submitted,
�QUIRE MWENTS _�Th_eet#
A. A,vicinity inap drawn atthe scale that shows the;relationship of the proposal to cxisting community facilities Which affect
or serve it,such,as roads,shopping areas,schools,etc. The map shall also show all properties,identify owners,
subdivislons,streets and easments,within 500 feet of Ale property, Stich a sketch may be;superunposed on a United States 4/4
Geological Survey rnap of the area,
lbw. The,site plan.shall be drawn at a scale of forty feet to the in
(I�=40 feet)or such other scale as the Planning Board may
deem appropriatq,,on standard 24""x 3,67 sheds,withcontinuation o�n 8�U2"x I I"'sheets as necessary for written.
information. The information listed belrow shall be shown on the she plan and conlinuation sheets.,
Name of the project,boundaries,date,north wow,and scale,of the plan.
D. Name and address of the owner of record,developer,mW seal ofthe engineer,architect or landscape architect, If the
applicant is,not the record ow ner,a letter of authorization shall.bLreir cdr fiown
ona theer,
q
E. The location and use of a]I existing and proposed structures within the property,including all dimensions of height and
floor,arra all exterior entrances,and All anticipated futureaddiflom and alterations.
E _Tb_eTm_ation of all present and propo&ed,public andprivate ways,off-street parking,areas,driveways,outdoor storage arms
sidewalks,ramps,curbs, paths,landscaping,walls and fences, 'Location,type and screening details for all waste disposal
containers shall also be:shown.,
The location,height,intensity and bulb type(sodfun-.�incandescent,etc-),Mall external lighting fixtuxes. The,direction of
illumination and methods to eliminate, h 179-6-020.
H, The location,height,size,materials and design of all proposed signs,. g)(6r,jVG S I&A TO Del KSE b-V)M YL 0 VER 1-,41 Y
The location of'a'lI'pr_cscat and proposed utility systems including;;
I. Sewage or septic system;
2. Water Supply system; A/A
3, Telephone,cable and electrical systems;and
4. Storm,drainage system including existing and proposed drain lines,culverts,catch basins,Ileadwalls,endwalls,
hydrants,,manholes and drainage swales.
J. Plans to prevent the pol ludon of surface or groundwater,,erosion of soil both during and after Construction,excessive:runoff
and flooding of other properties,as applicable. A Stormwater Pollution Prevention Plan(SWPM for all land devt1opment
activities(excluding RgH,cultural activities,on the site that results in land disturbance of One acre or more. A SWPPP shall
comply with therequircments of the DEC SPDES MS-4 General Permit and Chapter 147 of the Town o.f Queensbury
Code. It shall be at the discretion of the Manaing,Boardas to wheAer a SWPPP or an erosion and.control plan shall be
required for a site plan review project land disturbance of less than one acre,
K. Existing,and proposed topography at two-foot contour intervals,or such other contour interval as the Planning Board shall
allow. All elevations shall refer to the nearest Uniled States Coastal and,Gcodctic Bench Mark- If any portion of the parcel
is within the 1010-year floodplain,the area will be shown andbase flood elevations given. Areas,shall be indicated within IVA"
the proposed site and within 50 feet of the proposed site where soil removal or filling is rcqpired,showing dle approximate,
volume in cubic yards,
—landscape plan showing all existing natural land features than may influence the design,of the proposed use such as rock
outcrops,stands of trecs,single trees eight or more inches in diameter,forest cover and water sources and all plropmd
than.gcs to these features,includhig,sizes and types of plants. Water sources include ponds,takes,wetlands,and
waterco,urses,aquifers,floodplains and drai nap retention areas.
M. Und Use District bodarka within,500 feet of the site's perimeter shalt be drawn and identified on the site plan,iTw_jF
as any Overtay Districtuns that apply to the property, Alk
6
Site:Plan Review appi ication—Revisd October 2016
Town oft uua nsbury Planning Office-742 Bay Road,,Queensbury,'NY 12804
REQUIRE ME NTS (CONTINUE D) Sheet#
N. Traffic flow patterns,ww^itluun"i site, ntrances,anti exits, loading and unloading areas,as well as curb cuts oil the site and
within 100 feet of the site, Tile Planning Board may,at its discTedon, require a,detailed traffic study for large developments or
for tbolse in heavy traffic areas,which,shall include.
L The prQjf-cted number of motor vehicle trips W enter or leave the site,,esdinwed for weeklyand
annual,peak hour traffic levels,
2. The projected traffic flow pattern including vichicular movements at all major intersections likely
to be affected by the proposed use of the site-.
3. The impact orf this traffic on levels of service on abutting public streets and at affected
intersections- Existing and proposed weekly and annual peak hour traft levels mid road capacity
levels shall also be given.
For new construction or alteratirurus i;an—
y struiewre,a table contain ing the following inforingion shall be in,claudcdr
1. ErAimtedarca of structure W be usedfor particular purposes such as retain operation,office,
Storage,etc,;
2, Estimated,maximum number of employees-,
3. Maximum seadpgcapalcity,where applicable;an4
4, Number of parking spaces existing wild required for the iritended use.
P, L FlooFp-,Tffus7-
2. Elevations at a scale of one-quarter inch equals one foot(114"'-1 fool),for all exterior facades of the proposed structurc(s)
and"lor alterations to or expansions of existing fal showing design featuresand indicating the type arid color of materials
to be used.
Q. oi I logs,water suppJly well and percolation test results,and storm wider ti calculations as needed to determine:and
mitigate project impacts. A/4
R. Plans for disposal of construction and demolition waste,either on-51tc or at an approved disposal facility.
S. Plans for snow removal, including location(s)of on-site snow storage. I
T. An Environmental Assles&rnent.Form("E )l as required by the SEQ1RA regulations,wilb.Pad I com,pleted by the Applicant
shall be submitted as part of the application. If the proposed project requires a special use permit and an EAF has,been
submitted in conduriction with a special,use permit application,a dup'licate EAF is not required for the site plan application. 41A
U If an application is for a plarl or parcels on which more than one use is proposed,the applicant ri submit a single
application for all such uses.,provided the proposed uses are accurately delineated on a site pilar drawn pursuant to the
requirements set fhrth above., 'The,Pluuting Board may grant the application.with respect to some proposed uses and.not
others. FoT purposes of reviewing an application(W for SEQRA compliance)all proposed uses on a single parcel or on
contiguous,parcels shall be considered toW,leer.
A brief' arrative statement on how tine Fo7,—cct proposed for review furthers or is consistent with the vision,goals and policies
in the Town's Comprehensive Plan.
7
Site Plan.Review application-Revised October ,0 161
Town of Queensbury PlanningOfflce-742 Bay Road, Queensbury,NY 12,8014
Town of Queensbury Site Plan Pre-Submission Conference 'Form / Section 179-9-04O
1. Applicant Name: CC-�'�AQI_
3. Zoning Classification.
. Reason for RR '° "
Zoning Section#: c4u
6. Pre-, nuuhmission Meeting Note;. Provided Outstanding; Please provide
Deed I»
General Information complete
Site Development Data Complete
Setback Requirements Complete
Additional':Project Information Complete:
addressed
Requirements for Site Plan-Standards
Checklist items addressed
Environmental Forin completed
Signature Page,completed �
t...
"
Cc
05-e r
,
VI A
1 ; @ :, L,,,-),
SeU cm(A
DILL�j
Staff Representative:
-ate
Site Plan Review application—Revised October 2:0 16
Town uaf Quee Queensbury Planning Office-742 Bay Road,Queensbury,NY 128,04
Signature 'Page
This pagg includes,the 1.),Authorization to Act as Agent Fort; .) Engineering Pee Disclosure;3.)Authorization ' or Site "visits; 4.)
Other Permit Responsibi:litiesi ..)Official Meeting Disclosure and 6.)Agreement to provide documentation required,
Complete the following iffllue OWNER of the,property is not the same as the applicant.
Owner:
Des ates:.
As agent rep�arding: 'variance Site Plato Subdivision
ForTax'Map o.: _Section Block Lot
Deed fference;: Book Page Date
OWNER SIGNATURE: DATE::
APPLICANT'S AcEm,FORM
Complete the followingilf the APPLICANT is unable to attend the meefin or wishes to l represented by another Bad:
r
1wsirnates.
,s agent regarding, Variance Site Plan ubdi'VISioru
For Tax Maps No.: Section'tion Bleu.' Lot
MeedReference: Book page Trate
OWNER,SIGNATURE;-.- I— E.,
g.l ENGINEi ER1l+w_G FEE l��UR W Applications may be referred, to the Town consulting engineer for revie'w' of septic t e,siM storm
drainage. etc,as determined by the Zoning or Planning Department, Fees for engineering reviewer seryiecs will be charged directly to,the applicant.
Tees,.for engineering review will not exceed$1 p000 without no ifica ion to the applicant.
AUTHORI FOR T TT' - y signing this page and submitting the application,materials attached herein, the Owner,Applicant,
and hiAer/their a"t(s) hereby authorize Che Zoning'Board or,Planning Board and 1'°'ow n.Staff to enter the subject properties,for the purpose of
reviewing the application submitted.
4. 0 L IT RESP9NSIPJL1T1KS' ther permits may he required ffcr constration or alteration activity subsequent to approval by the
Zoning Board or Planning Board. It is the applicant's responsibility to obtain any additional permits.
SJ QE EET'LN_I tTT'E I I SURE_ It is the practice of the CQmmunity Dcvelopmelit Departt=nt to have a designated
stenographer tape record the proceedings of meetings resulting ffrom application,and minutes transcribed from those tapes constitutes the official
record of all proceeut:itnp.
AG EEMI, VIL_E UM11Elwl"l i 10 REQUIRED, 1,the undersigned,haw thoroughly read and,understand the instructions
for submission and agree to the submission requirements, l acknowledge no construction auctivide°s shall he commenced prior to issuance:of a vapid
pernntiit. I certify that the application, plans and supporting,trnaterial;s area true wW complete statcmenti-description ofthe exisfing conditions and the
work proposed, and that all work will he perffonned in accordance with the approved plans and in tonformance with local zoning regulations, I
knowledge that prior to cCcupying the facilitles proposed,I or rnny'agents,with obtain a cerfificate of occupancy ,necessary, I also and t id that
Vwe nmay be required to provide an as-built survey by a licensed land surveyor of all newly constructed facilities prior to issuance of a certufficate of
occupancy
I have read agree to the above.
ole
i tt,at (4plica tt] Print Name [Applicantl[ApplicantDate signed
Signature [Agent] PrutttNaralue I[Agent] Date signed
q�
Site Plan Review application Re,unised Oictober 2016
"1'OW n.of Queensbury PlariningOffice-742 Bay Rot ad,Queensbury,NY 128'04
Short Environmental Assessment Form
Part I - Project Information
Inslruclions for ComIaletin
part I -Project Informa I ion, The applica ot or project Sponsor is:responsible for the completion of Pa rt I. Responses
become part of the application for approval or funding,are subject to public review,aid may be subject to further-verification.
Complete Part I based on information currentlyavailable, If'additional research or investigation would be needed to fully
respond to any item,please answer as thoroughly as possible based on current infortnation.
Complete all items in Part L You,may also provide any additional information which you believe will be needed by or useful
to the lead agfncy;attach additional pages as necessary to Supplement any item.
Part I -Proloct and Sponsor Information
Name of Action or Project:
JAI,"' kve^
J tie- Rf
Project Location Nescrib;l,and attach a lobation
/V&2 d-Alei- 12t I -
Brief Description of Pro�pos�ed Action:
e-x
oew
Name of Applicatitor Spionsor-
'Telephone: 5y,
E-Mafl: Te—
Address:
It)63 1'�T
City/Po' State: Zip Code,,
0
NO
1.Doestheproposed action only involve the ption of a plan,local law,ordinance, lig YES
administrative rule,,or regglation?
If Yes,attach a narrative description of the intent of the proposed,action,and,the enviroomicatal resources that
may be affected in the municipality and proceed to Part 2. If'no,continue to question 2,
�2. Does the proposed ac6m require a permit,approval or fru .din fforn any other govermnental Agency?—-NO— YES
If Yes,list agency(s)natne and permit or approval:
7-0c,", aA
3.a..Total acreage of the site of the proposed action? acres
L Total acreage to be physically disturbed? S ?,F
ed
c�Total acreage(project site and any contiguous prope wn
or controlled,by the applicant or project sponsor? —tires
4. Check all land uses that occur on,adjoining and near the proposed action,
Fl Urban 0 Rural(non-agriculture) E]Jndustrial [MCornmercial OResidential(suburban)
Ell'orest DAgriculture DAquatic E30ther(specify):
Parkland
Pagt- I of 3
. 1s the proposed action,
. permitted use under the zoning regulations? i�l E 'II
OMMEb. onsistent with the adopted comprehensive plan?'6. Ls the
e ,. .
pr p .ad action consistent with the
larudscrup predamimaurt character of tlue existing built or natural NO YES
7. is the site of'the proposed action located in,or does it adjoin,a state Irsted Critical nvironmental Area's NO SES
If Yes, identify: X LJ
mm„
�..
8. a.Will the proposed actio;result in a substantial increase in traffic above present levels? NO YES
b.Ate public transportation service(s)available at or near the.site of the proposed action?
El
c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action?
9.Does the proposed action meet or exceed the state energy coderequirements? l �
If the proposed action will exceed requuire eats,des�eribe design natures amid technologies.
YES
10. Will the .... .,�,�.
p.rouposed action connect two an.existing public/private water supply? I'wT 1
If No rdescribeuucthrdfor providing potable water: At&v;y' ;
11.Will the:proposed action connect to eXistinwastewater otillities l
�O YES
If No,describe method forrovidirr wastewater treatment,
tutrerut:
12.. a.Dees the site:contaiuu a structure that is,listed on eithrer the State OrNational'Re ister of historic l 0 "lu"E
Place$?
b.is the proposed action located in,an.archeological sensitive area? a7 '
Li
portion
proposed , � adjoining the proposed action,contain N YES
Na.
l3. a.bees auurticuu of the site ci flue aced action or lands ad"rriuroiru
wetlands or other~r atcrbodies regulated by a federal, state or local agency?
b. Would tile sed a tioru h sicall alter,or encroach iuuto,any existing wetland or taterbody? �1
11 p y y � 1—..,.1
If'Yes,identifytho wetland or watu.rlrrud and extent sof alterations in square feet or acres.
14. i ti thelikely p
EI Shoreline 0 Forest I, � ,oj�euu#site. h�acle all that apply:
typical habitat types that occur ru c�ltuural,� ras;slbarudsood on thu: l�arly uuuid-sureccesssin,nal.
Wetland Urban Suburban
1 5. otlue Mate a� p'eilerrul government as threatened p animal,or as,saciateal habitats,,listed Iii '9t'1
i
by
proposed n any species of
atened or endian ? t. i
16. is tare project site located in the 100 year flood plain? NO YES
17. Will the proposed action create storm water discharge,either h'om point or r on—poirut sources? NO !y
if Yes,,
a.Will storruu water discharges flogs to adjacent propeuties? ONO EJYES
b. Will storm,Mater discharges be directed to established conveyance Systems runoff and storm drains)?
1f Fess briefly describe: NO []YES
Page 2 of
1 .Des tho p�re,pe d auction,include construction or ether activities that result it)the impoundrn=t of NO YES
rater or ether liquids(e.g.uTtvition pond,waste lagoon,damy?
If Yes,explain purpose and size;;
19, Has,the site of the proposed action or an adjoining prepert 'laeen the;location of an a,ctivo or closed NO YES
solid waste management emen;t facility?
If Yes,describe:�..
0, Hes tlue site of the prod action or an autgeioing property been tlae%6k*t of tmedistien(ongoing or NO YES
completed)for hta rdo uswaste?
If Yes,describe;
1AFFIRM THAT-THE INFORM+N,TI ROVI BOVEIS TRV AND ACCURATE TO TUC,HEST OF MY
KNOWLEDGE
Signature:
PRINT F Page 3 of 3,
Agency Use Only [I f a pplica ble
Project,
Date.
Short E n vironmental Assessment Form
Part 2' - Impact Assessment
Part 2 is to be completed by the Lead Agency.
Answer al I of the f6ilowing questions in Part 2 using the information contained in Part I and other materials submitted by
the projectsponsor or otherwise available to the reviewer. V4ien answering the questions the mviewe-r should be guided by
the concept'Have my responses been reasonable considering the scale and context of the proposed action,?"'
No,or Moderate
small to large
Impact Impact
may nmy
occur occur
L Will the proposed action create a material.conflict wiah.an adopted land use plan or zoning
2. Will the
pro,posed action result in a change in the use or intensity of use of land?
3. Will the proposed notion impair the character or quality of the existi ng community?
Y?
4. Will the proposed action have an impact on the environmental characteristics,that caused the
establishment of a Critical Envimmental Area(CEA)? El 1:11
5., Will the proposed action result in an adverse chain gp in the existing level of traffic or
affect existing,in.frastructuro for mass transit,biking or'walkway?
6. Will the proposed action cause an increase in the use Of energy and it:f4fls to in.corporate.
reasonably available energy conservation or renewable energy opportunities? Lj
7. Will the proposed action impact existing-
a.public/private water supplies?,
Efb.,public/private wastewater treatment utilifies? E
8, Will the proposed action impair the character or quality of'i mportant historic�archaeological,
architectural or aesthetic�resources? El
9. Will the proposed action result in an adverse ehange to natural resourm(e.g.,,wetlands,
wawrbodies,groundwater,air quality,flora and fauna)?
10. Wi II the,proposed action result in an increase in the potential for erosion, flooding,or drainage
problems? 0 E]
IL "Wil I the proposed action.create;a hazard to environmental resources,or human health?
LJ
PRINT' FORM Page 1 oft
AgeIII 1 1111 11 11,11'
Rill I, I
Date.
ShortEnvironmental Assessment Form
Part 3 Determination offtnifirance,
For every question in Part 2 that was answered""anoderate to large impact way occurs,or if there is,a need to,explain why a
particular element of the proposed action may or will not result in a significant adverse environmental impact,P—lease
complete Part 3.Part 3 should,in sufficient detail,,identify the impact,including anyrnensures or design elemeats that
)rave'been included by the Project sponsor to avoid or reduce impacts. Part.3 shotsid also explain how the lead agency
determined that the impact may or will not be significant.Each potential, impact should be assessed considering its setting,
probability of occurring,duration,irreversibility,geographic scope and magnitude. Also consider the potential for short-
term, long-tem, and cumulative impacts.
Check this box ifyou havei�i—
de ,m j� d, based on the informatioji and analysis above,,and any suppoaing do—cumentation,
that the proposed action may result in one or,more:potential ly largP or M gnificant adverse impacts and an
environmental impact statement is required.
Check this box if you,have determined,based on the inforination crud analysis above,and any supporting documentation,
that the proposed action will not result in any significant ad verse environmental impacts.
Nam of Lead Agency Date
Print or,Type Name of Responsible Officer in Lead.Agency 1. Title of Responsible Officer
...... Signature,of Responsib Fe ZFfFicer In',lam Agency Signaturoof Preparer(if differen,t from Respoin"sible Officer)
PRI 11 NT F1M Page 2, of 2