Site Plan application TOWN OF' QUEENSBURY
Site Plan Review Application 0 IGIN4L
.Review Process:
1 w Required pre-submission meeting with staff'to deterrr, a general completeness Lo be held ne Iatel:than .1
uadeadline dna . all 1 761-82,65 or 1. 761-82210 for an appointment.
2. ula:n- ttml of complete application. 1 origM and14 capes of the application package y monthly deadline.
3. Determination of application completeness. All accessary information must be provided and appropriate
fee(s)paid for consideration for placement on an agenda for that month.,
4. Incornplete a lica!Lans will I not be considered for DILeement on -An-.xl agenda until Il missing
informa,tign has been submitted.
, Submittal to Warren Cowry Planning if applicable.
6. Planning Board me tin , generally the third & fourth Tuesday of each month. You will be advised in
writing as to w1fich meeting,to attend.
7. Following the meeting ou w ill be provided with a copy of the resolution tatia the Board,'s Board,' decision on
your application, if your application was approved, the next likely step is a Building, Permit, Final
drawings must be provided for the next phase ofreview. If your application was denied, your project cannot
proceed as submitted.
DOCUMENTATION 'Gi '' hgrd copj & electronic
Please submit I original st.copied of the completed pplicatio package to include:
GCompleted An iona es 2-9,signed &daled
* re-Submission Meeting 1"o * ,signed by std
Copy of Deed
+� hoe list & flet Pjjn
Environments] Assessment on��ru for any non-residential prosect;
$100 0 10,000 sq. .), :250 ('10,001 — 30,000 sq. f1. $500 (30,01 -100TG00 sq. fl.); 1,000
(100,000+ sq. ft.)
Craig Brown,Zoning :dm,inistrator emi, b E9Hj Met
,Laura Moore, Laud Use Planner er IM qo—r-e-@a auucon b ry.net
Sunny Sweet, Office Specialist—Planning herrn r�eensbn suet � ��� � f-822;4
Visit our ww ebsi at n n b:u,r .net icor,further inf rniation and fps
Site Plan Review application—Revised October 2016
Town of Queensbury PlanningOffice-74213ay Road,Queensbury,NY 12,E
General InformationZoning Distfict:
�
Tax Parcel ID Number:
Lot sem:
A PR 1
ailedDet
j fan hud c M PM Os n it: ^"°a���,a 9 � .Yk ^ti "� �� "'�
lie
HN 0 FN MC�"I�.
Location of projeev
w
H Phone Cell,,
"' ear ,Phone Fax
Re9_3 CIA k
- H: -__
TM lhl v
Agent's Name-me: ddre :
r
Horne phone Cell:
E-mailWork Phone Fax
Owner's Name Address
49
Home phone x ell
'Work-Phone, Fax
E-mail
2
Site Plan Ftoview application—Revised October 2 16
Town of Queeosbuq Manning Office-742 Bay lead,Qaeensbury,NY 12804
Site Develolme..ntData
Area,/'ape Existing q. ft. Proposed Total sq. Vit.
Addition s . .
A. Building footprint
w
. IaedGarage-
C
. e�essor Structure(s)
. ,.
I . Paved,gravel or,other hard surfaced area
FE7' r h s/Decks
F. .
G. Total Non-Permeable [.add -I?
4y 11
H.. Par [Area (4-3,560 sq, C.,/acre)
4
I. Percenta e f lrnW rweab]e Area of Siw [1-1G/H)
Setback Requiremcmts
Area Required Existing Proposed
Front[1)
ro�it[ ]
Shoreline
Side Yard [I]
Side yard [2)
Rear Yard
�Rear Yard [:2]
Travel Corridor
Height[
Permeabili
No.of parking spaces
Site Mari Review application—Revised October 20,16 3
Town of Qtieensbury Planning Offime-742 Ba Road,Queen9bur'Y,NY 12804
Add itio l Project Information
1. Will the proposal require,a Septic Variance from the Town Board of Health.?
. if the parcel has previous approvals, list application number(s): j"" "o� /,
. Does this prqJect require coverage under the New York State Pollutant Discharge Eliminationstern
( PD ) Permit Program
4. Estimated project duration: 'Start late End.late 2 �
,. Estimated total cost of project;/, �0 4-
.. Total area of land distiobance fbrproject, g a ��
Floor Area Ratio Worksheet
FLOOR AREA RATIO (FAR) -- The relationship of 4baild ng size to lot size-, derived by dividing the total
building floor area by the lot size in square feet, yielding a percentage.
Zoning District Symbol Floor Area patio [FARI
Waterfront Residential VVR 0.22
Commercial Moderate/Intensive Cly CI 0.3
A. The combined area, of all square footage, as mneme f`tom exterior walls of all sutures on the property,
including all floors 'the structures,, garages, basements and attics with more than five ) feet of ceiling
height and covered porches. Building square footage does not include: Open deck, docks and that portion of
covered docks extending over grater and one storage shed of one hundred twenty (1 20) square feet or less.
Any additional, sheds will'be included. (See"'FLOOD AREA R.ATI .
. Connnercial or industrial:the total area in square feet as measured from the exterior of theoutside wal,ls of a
building or structure, and when applicable, the sum total of:all floor areas of the principal and accessory
buildings or structures on the project site,
A. Parcel Arra
H. Exi,sting Moor Area. s. . ft. I see above definition
C. Pro used Additional Floor Are
sq. ft.
D. Pro osed 'ental Floor Area sq, R.
E, Total Allowable Floor A see above table
*If D is larger than'E. a variance or revisions to your plan may be needed. Consult with Staff.
4
Site Plan.Review application—Revised October 2016
Tow of Queensbuy Plarnning o -747 Bay Road,,Qwensbury,NY 12804
§ 179,-9-0uirelent s for Site Plan, Aimlarval.
The Planning Bard shall not approve a Site: Plan, unless it first, determines that such. site plan, tneets the
following Standards. Please prepare response s to each of the following trap'
ics.
STANDARDS,
.A. no Proposed proJect furthers or it consisaeput awith the policies paf'the gown's oarnpr�iuensiw+e Ilan,
The Proposed PrPjmt complies with all other requirements of this C—hWer,incldi the site plan review standards as set forth'iim-n-P�Ia=nwWW"h
F of this section,the dimensional,bulk and density regulations of the zoning district in which it is proposed to be,located(Article
3 and
Table 4 the applicable requirements ofall other Articles that aply,
C, The site plan cricoumges pedestrian activity—internally and,if practicable,to and from the site,withpedestrian paths or sidewalks conneaed,
to adjacent areas,
The sire plan must cowrefiwrm to Chapter 136 Sewage,and—Sewage M'Wosal,Chapter 147 Stormwater Managem,, nt Local Ei-w--,"and—olher
applicable local laws.
E. The proposed use shall be in hannony With the general purpose:or intent of this tempter,specifically taking into account the location,
character and size of the proposed use and the description and purpose of the district in which such use is Proposed,ft,nature and intensity
oaf the activities to be involved in or conducted in connection with the proposed use and the,nature:and Me of any increase in the burden on
supporting public services and.fadlifies which will follow the approval Ofthe proposed usc.
F. The establishment,maintenance and operation of the proposed use will not create public hazards from traffic,traffic congestion or
parking of vehicles arid/or equipment or be otherwise detrimerdal to the health,s*ty or general welfam of persons residing or working in
t he neighborhood or to the general welfare of the town. Traffic access,and circulation,road intersections,road and drivewaywidths and
traffic controls will be,adequate,
G. Off-strcct Farking,and 190ading facilities will be appropriately located and arranged EW sufficient to,meet traffic anticipated to be gentraled
by the new use., The establishment of vehicle links between parking areas Of 4acm,t proptrdes are provided where feasible. This furthers
the'Tom's,goal of reducing curb cuts and reducing congestion. A twenty-foot wide connecdon is required. It adjacent properties are either
undeveloped or previously developed without having made Provision for future,lin then a future connection must be ideutifil an
or such future linkage when,die:time arises. The Planning Board may require proof that the
provided for in tht site plan,under review f kage ed
applicant his rna&contact with adjacent Property owners for purposes of coordinating linkages with 4acem properties.
............
.H. e prqject shall not have an undue adverse impact upon the natural,scenic,acsthefic,ecological,wildlife,historic.rrecreational or open
space rth
'resources of the town or e Adirondack Park or up on the adequate provision of supportftM facilities and services made necessary by
Ole project,taking into account the tornniercial,industrial,residential,,recreational or other benefits that might be derived from the - t
In making the determination,hereunder,the Planning Board shall consider those factors pertinent to the project contained in the 105-
&-velopment considerations set forth,herein under§ 179-9-080 of this Chapter,and in so doing,the Planning Board shall make a net overall
evaluation of the project in relation to the developtrient objectives and Soneral guidelines set forth.in§ 179-9-090 of'this dole-
The provision for and art-angement pedestrian traffic access and eimulation,walkWay Amctures,control of intersections with vehicu'lar
traffic and overall pedestrian convenience shall be safe and adequate for pedestrian,movement. pedestrian connections between adjacent JA
sites shall be provided to encourage,pedestrian use. I
Storrawater drainage facilfties will prevent an inerease of post development drainage flows as compared to pre-development drainage flows.
Drainage of the site shall recharge ground water to the extent practical, Surface waters flowing Off-site shall not degrade any streams or
adversely affect drainage an 4acmt properties or public roads, raeflitics sha.11 be in conformance with iW drainage standards of Chapter
147 of the Town Code and the Town of'Queensbury Subdivision Regulations where applicable.
K. 'Me water supply and sewage disposal facilities will be adequate and will met all applicable and current requirements set forth by
Department of Health regulations and Chapter 136 of the Town Code.
The adequacy,type and arrangement of trees,shrubs and other suitable plantings,tandscaping and screening shal I eff-ectively provide a
visual and.16r noise buffer between the applicants and adjoin!it&lands,including the maximum retention of existing vegetation and
maintenance,including replacement of dead or deceasedMants,
M. Fire lanes,emergency zones,and fire hydrants will be adequate and meet the needs and requirements of emergency service providers. Alid
N. The design of structures,roadways and landscaping;in areas susceptible to pondinp,flooding andVor erosion will min hnize or avoid such
impacts to the maximum extent practicable.
L I
L, '�"!lu�e site plan cosufiarn°rr to flue desi,gru standards,landaeapinp,�kanalarols and perf'oprmanc satauupdaardr of'tluis o:hapter.
5
Site Plan Review applications-Revised October 2016
TOWn of Queensbury Planning;Office-742 Bay Road,Que"sbury,NY 12804
§ 179-9-050 Chreklist-Application for Site Plan Review.
,Application materials and site plan shall include sufficient inf rm,ation for the,Boardto review and provide a
decision. The applicant is to provide a site plan drawin,g and all attachments that address items A-V. The
applicant may request a waiver from AN and is to provide reasons for waiver(s)iquested. Please label
infonnation to be submitted.
REQUMMENTS Sheet4
Via. A vicinity map drawn at the scale that shows the relationship of the proposal to existing community facilities which Wm—t
or serve it,such as roads,shopping mss,schools.,etc. The reap shall also show all properties identify owners,
subfflvisions,Streets and,easernents within 500 feet of the property, Such a sketch may be superimposed on,a United States
holoiawalSurvey an of the amiL
13. The:site plaaap shall be drawn at a scale of forty feet to the inch,(V—40 feet)or such other scale as the Plarming—Board may
deem appropriate,on sumdard 24"x 36"sheets,with continuation on 8 V2 11X I I"sheets as necessary for written
information. The information listed below shall be shown on the site plan and,cmitinuation shects.
C. Narric of the project,boundaries,date,, north arrow,and scale of the plan.
D. Name,and address of the owner of record,deveto er,and seat of the engineer,architect of landscape
p architect. if the
..Pp
-0.licant is not the record owner, a letter of authorization shall he required from the owner.
E. The location and use of 0, existing and proposed structures within the propeny',including all dimensions afheight and
floor are: � all exterior,entr
!����d all antkip.ted futu�re additions and alterations.
F., The location of all,present and proposed public and private ways,off-street parking areas,driveways,outdoor storage areas,.
sidmalks,ramps,curbs,paths,landscaping,walls and fences, Location,,type and screeniAg details for all waste disposal
containers shall also be shown,
G. The location,height,inlevisity and—ba-11"type(sodium,incandescent,etc.)of all external lighting fixtures.. The direction of
illumination and methods to eliminak,glare onto adjoining, series tmist,also be shown,in corn lienee with§ 179�4�020L
H. 'The location,bright Sim,material's and design of all proposed signs.
The location of all present and proposed utility systems including-
1. Sewage or septic system;
2, 'Water supply System; f
3. Telephone„cable and,electrical systems,;and — 00ill 45-
4. Storm drainage,system including existing and proposed drain lines,culverts,catch basins,headwalls,endwalls.
Wrants,manholes and drainage swales.
Plan,to prevent the pollullonolsurface or groundwater,ero,lonol soil both during and
after construction,excessive runoff
and flooding of other properties,as applicable;. A Stormwater Pollution Prevention (SWPPP)for 0 land development
"Pollution
a
activities(rxcludlng agriculftual activities)an the ii=re=utts i,=andeistM=rbancPe of one am or mcgeb A'S PP shall
ee
'Comply with the requirements of the DEC SPDE S MSA General Perinit and Chapter 147 of the Town of Qunsbury
Code. It shall be at the discretion of the Planning,Board as to whether a SWPPP or an emion.and control plan shall be e V-Xwl�-
�required f6r 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 intervalas the Planning,Board shall
allow. All elevations shall refer to the nearest United States Coastal and Geodetic Bench h4art If any portion of the parcel
is within the 100-year floodplain,the area will be shown and base flood elevations given. Areas,shall be indicated within
the proposed site and within 50 feet of the proposed,site:where soil removal or filling is:required,showing the approximate
volume in cubic yards.
L A landscape plan showing all existing natural land features than may influence the design of the proposed use such.as rock
outcrops,stands of trees,single trees,eight or more inches in diarmter,forest cover and water sources and,all proposed
changes to these features,including si7es and types of plants. Water sourecs include ponds,lakes,wetlarvis and
watercourses,aquifers„floodplains and drainage retention areas.
M. Land Use District boundaries within 500 feet of the site's,perimeter shall be drawn and identified on the site plan,as well
as any Overlay Districts,that apply to the property.
6
Site Plan Review application—Revised October 2016
Town.of Queensbury Planning,Office-742 Bay Road,Queensbury,NY 12804
REQUIREMENTS .IE bt
Traffic flout/patterns within the site,entrances and exits,loading and unloading;areas,as well ascurb cuts oorn the site and
within 100,feet of the sits The Planning Board m,ay,at its discretion,require a detailed traffic study for large developments or
fear those in heavy traffic arcaa„which shall include:
1. Dw projected number of motor vehicle trips to eater or leave the site,estivanatcd for weekly and
atnrnual peals hour traffic levels; �
. The projected traffiCL flow pattern including vehicular movements at all major intersections Iikely ,✓°� '
to be affected by the proposed use of the site,.
3. The impact:of this traffic on levels of service on abutting public streets and at affected
intersections, Existing and,proposed weekly and annual pear hour traffic levels and road capacity
levels sbarll also be given.
. for new cwistruction or alterations to any structure,a table co ntainmi",the tollcwiog,information shall be includedm
1. Estimated area of structure to be used forparticular purposes such as retain operation,office,,
storage,etc.,
2. Estimated maximu rn number ofemployecs;
. lwf=Imum seating capacity,where:applicable;and
4. Number ofpat ing spaces existing and required for the intended,use,
pe 1. Floor Plans.
Elevations at;a scale of'one-quarter inch equals one foot(1/4":- 1 foot)for all exterior facades of the proposed structure(g)
and/or alterations to or expansions of existing facades,showing design features and indicating the type and color of materials
to he used,
Soil lop,water supply well and peroolationn test results,and storm water runoff calculations as needed to determine aond
mitigate project impacts
R. Plans for disposal,of construction and demolition waste,either on-site or at an approved disposal facility.
ry
Plans for snow removal, including location(s)ofond-site snow storage.
T.
Ara Environmental Assessment Form("EA:")as required by the SEQRA regulations,with Fart l complewd by the Applicant
shall be submitted as part cf'the application. if the proposed project requires a special use;permit and ars p L"has;been
submitted in co nji mcdoun with a special use permit application,.a duplicate EAF is not required for the site plan application.
U. If an application is for a parcel or parcels on which more than.one use is proceed„the applicant may submit a single
application for,all such uses,provided the proposed asses are accurately delineated on a.site plan drawn pursuant to,the
requirements set fcardu;above. The Planning Board may grant the application with resped to some proposed um and not
others. For purposes ofreviewing an application(and for SE,QRA compliance)all proposed uses on a single parcel or on
contiguous parcels shall be considered togethcr, IVIA
A brief narrati-ve statement on how the project pro...osed for review furthers or is consistent with tine visions,goals soul policies
in the Town's Comprehensive Plan,
w
7
Site flan Rev iow application—Revised October 201
Town.of Queensbury Panni , Office-742 Bay oa,d; Queensbury,I^+iY 12804
Town of QueensburySite Plan Pre-Submission Conference Form d Section 179-9-040
-040
1. Applicant Name: -
, Tax Map.1D a,
. Zoning CNssffication M
5 kJD C( ' )
4. Reason for Resew. 1 �11
. Zoning Section N: na Pte � Aly-
s , P ,_ mrheea
rs maaw Meefing l art m
Provided Outstanding, Please p e b
Deed
General Information complete
bite Development DataComplete:
Setback Requirements om,plete
Additional;Project Information Complete
FAQ.aaddres�W AZA
Requirements for Site Plan-Standards
becklist items addressed
nen
Environmental Form oompleted
Signature Page completed.
J
�Y.
_,C .. r C,
M
„
-
-412
. `�
r d A 14
,
N
Staff Representative:
Applicant/Agent; LMIL Date: �
Site Plan Review application— eyisOctober 20I '
Town of Queensbury Planning;Office-742 Bair Road,Queensbury,NY 12804
Signature Page
This page includes the 1.)Authorization to Arra as Agent Form..: 2-) Engineering peeDisclosure; .)Aethorizadtion for Site Visits; 4.)
Other Perm,it responsibilities; 5.)Official Meeting Disclosure and .)Agreement to provide:documentation required.
Complete the following if the OWNE,R,of the property is not the same as the applicant
ner
lam", testy
As agent regat-ligg: _... Variance Site Plan Stibdivision
For Tax Map o. Section 13lockLot
fs
Deed Reference-, Pago Pgo �Dart
OWNER SIGNATUR& DATE
APPLICANT'S AGENT FR w
Complete the 16llo rim If the APPLICANT is unable to-attend tl meeting or wishes to be represented by another paw.
Owner:
Designates,
As agent regarding. Variance Site Pl", Subdivision,
.For Tax Map,'trio.: Section Block Lot
Med fi nce: Book Page Tate
2,.) ENGINEERIN'rz FEE DERGIA
JfiM, Applications may be referred to the Town conm4ting engineer for review of septic design, storm,
drainagetc,as determined by the Zoning or Manning Department. pees for engineering review spicas will becharged�diaectly to the appfica ,t.
Fees,for engineering reviews will not exceed S 1,000 without notification to tele applicant
I AjjjHQRjZATiiai�'her�tlaeaa ea ffl fQR authorize YJLS t . y sigaaing this and submitting the application materials attached herein,the,Owner. pplicant,
and he Zoning Board or Planning Board ,and Town 'Staff to eater thesubject properties fbr thepn of
reviewing the application submitted.
d � Other peruruits may be required consft ctiouan or alteration activitysubsequent to approval by the:
�"kII�R,_PEltl4d' 1IdYI.JTIE_;
Zoning Board or Planning,
SP0NI Board. It is the applicant's responsibility for obtain any additional permits.
CIA ING . t' URE: It is the practice of the ovum unity Development, Department to have a designated
stenographer tape record the proceedings of mectin,gs resulting frorn application„ and minutes transcribed from those tapes constitutes the official
record of all procoe,dings.
. AgREMN71M I' VIDE DO"ENI&TION RA ; I, the undersigned,have thoroughly ram and,understand the instructions
for submission and age to the submission r-equir ents,l acknowledge no construction activities shall be commenced prior to issuance of a'valid
permit. I certify Haat,the application,playas and supporting materials are a true:and complete statement/description of else existing;conditions and the
work posed, and that all work will be performed in accordance with the approved plans,and in conformance with local coning regulations. t
acknowledge that prion to occupyiang the facilities proposed,l or my agents,will obtain a certifaoate of occupancy as necessary, 1.also,understand that
I/we may required to provide an -baullt survey by au licensed land surveyor of all newly constructed 1 ,cilities prior to issuance of a certificate of
occupancy
1 have ted,mod car to t7'a'oov e.
.� z V
4%gnature ultaur [ 4ppli sm Print Name ( .pPlicant] Date,signed
Signature[Agent) _ Print Name [,Agent] Date signed
Site Plan Review,application—rovised Ober 2016,
Town of Queensbury Planning Office�742 Batty load,Queensbury,NY 12804
Age acy Use On ly I If a pplicable
project:
Djute:
Short Environmental.Assessment Form
Part 2 - Invact Assessment
PaIrt 2 Is to be completed by the Lead Agency.
.Answer all of the following question,$in Part 2 Using the information containod in Part 1 and other Inaterials submitted by
the project sponsor or Aer-wise available to the reviewer. When answering,the questions the reviewer shuld be guided by
the concept"Have iny respfonses,beett reasonable considering the scale and context of the proposed action?",
No,or Molderate
small to large
impact impact
may may
............... occur 04Xu r
1. 'ill t le proposed actio�-C—Teatea maGRTZonflict an adopted land use,plan or zoning
regulationO 11 1:1
2. Will the proposed action result in a change in the use or intensity Of use ofr land,?
........... El 1:1
3, Will the:proposed action impair toe character or quality of the existingc*mmunity?
—7
4. W.11 the proposed action have,an in pact on the environrnerftl characteristics that causa the
establishment Df a Critical Environmental Area(CEA)? 1 El Li
5. 'Will the proposed action m. cult in ark adverse change:in the existing level of traffic or
affect existing infimstructurefor.inass tmnsit,biking,or walkway? E]
6. Wi I I the proposed action cause an increase in the use of energy and i t fails to incorporate
reasonably available energy conservation or renewable energy opportunities? [3 1:1
T Wi H the proposed action impact existing:
a,public I private water supplies,?
b.public/Private wastewater treatment utilifies?
Will the proposed,action impair the character or quality of important historic,archaeological,
architectural or aesthetic resources? El
9. Will the proposed action result,in an adverse change to natural,resources(e,&.,wetlands,
waterbodies,g=ndwater, air quality, flora and fauna)? E] El
10. Will the proposed adion result in an increase in the potential for erosion, flooding or drainage
problems?
11. Will the proposed action create a hazard,to environmental resources or human health?
El
PRINT FORM Page I of 2
AcanOr Use Only lit a � ttIca
Projecb
Dates
Short Environmental Assessment Form
P�art 3 Determination offtnificance
For every question in Pad 2 that was answered"Moderate to,large imPavt may occur", or if there is a need to explain wily a
paiti,cular element of the proposed action may or will no,t result in a significant adverseenvironmental impact,please
complete Part 3. Part 3 should,in suffloient detail,identify the impact, inchiding any measures or desig�n elements that
Dave:been included by the project sponsor tolavoid or reduce impacts. Part 3 should also explain how the lead aW-cy
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-term and Gurnulativeimpacts.
("beck this box if you have determina,based on the in"fiormation and analysis above,and any supporting documentation,
L--J' that the� proposed action inay :result in one or in,are potential IY W,ge or si gni floant adverse impacts and an
environmental impact srtatefn,, t is required.
Check:this,b*x,:i f you have determined,based on the information and amlysis above and any supporting documentation,
that the proposed action will notresult in any significant adverse environmental impa'ds.
Name of Lead Agency Date
Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer
t:Officer
r
Signature of'Rosponsible 6—fficer—in L-��d�enc; Kiij�,—rpf Pr ce:
au 0 cp��:�r(if—differe�il:�ini—Recsprush le f ter
EPRINT FORM Page 2 of 2
:�
i 8.Does the proposed action include cunstniction or other activities that re-Bult in tine impoundment W NO V FST
water or other liquids(e.g.retention pond,waste:lagoon, am')?
lffe%explain purpose and size:
19. i°ias the site of the proposed action or an adjoining property been the location of an active or dead F.
so,hd waste management facility?
If Yes,describe.
0.Has the site of the proposed action or an adjoining property been the subjjea of Ternediation(ongoing or NO YES;
completed)for hazardouswaste'?
If Yes,describe: I
I AFFIRM THAT THE INFORMATION PROVIDEDAROVE IS TRUE AND ACCURATE TO TFM BCST OF M' `
KNOWLEDGE
Applicant/sponsor name-
Signature.,
ame;i ature.,
PRINT FI; Page 3 of 3
Short EnvironmentalAssessment For
Instructions for Coniplej Un
Part l -Vrr►j"t Infcrrrration. The applicant or project sponsor is,responsible for the completion of Part 1, Responses
become part of the application forapproval or fUndirr ,are subject to public raw ,iew,and ma,y be subject to further verification.
Cornplete part I wed on infor ati" currently available. If additional research or Investigation would be needs ,fully
respond to any item,please answer as thoroughly as possible based on current:information,
Complete all items in Part L You may also provide any additional information which your believe:will be needed by or usefl
to the read agency;attach additional pages as necessary to supplement any item,.
T'ar't l roj t and 'Sponsor Information
Nam,a of Action or project:
Project location(describe,and attach a location ma,0;
Brief Description of Proposed-Action,
i
Name of Applicant or Sponson Ti elephcine:
E'1' ail .Address-
ity/l ': State: Zip Code,
.
1,boos the proposed action only involve the legislative adoption of a plain, local law,,ordnance, NO YE
administrative rutile,,or regulation?
If Yes,,attach a narrative description of the intent of'tlte proposed action and the nvi;roru-nental resources that
may be affected in the rminicipality and proceed to Part:JMa If no,,continue to question 2.
. fees the proposed action,require a permit;approval or funding firorn any other govermnental Agency? ICICI YES, I
if Yes, hist agency(s)name and pernu:it or approval:
.a.Total acreage of the site of the proposed action? acres.
b Total acreage to be physically disturbed? acres
c.Total acreage(project site and any contiguous properties)owned
or controlled by the appl:icarn or'progect sponsor? -acres
acres
4. Check all land uses that occur on, adjoining and.near the proposed.,action..
Urban Rural(non-agriculture) ElIndustrial owrnmercial Residential(surburlban)
Forcst ClAgricultare ElAquatic E:10ther(specify),
OParkland
Pagg 1 of
5. Is tineproposed action NO }
ES NIA
a.A peru ittedl use under the zoning regulations? �p
b.Consistent with the adopted comprehensive planus' Li
�
" . is the proposed action caeurusistennt with the predouainarnt cha^acter of the existing built or natural NO, YLS
lam?
larndscuu
Is,the site of the proposed action located in,at dotes it adjoin,a state listedCritical lrowironnrnuern'tal ? CC~l''0 YES
If Yes, i
d�errtufy°
. -
E]
, a; Will the proposed action result in a substantial increase in traffic above present,levels? YES
b—Are puublic trarnsportatioru service(s)available at or near the site of the proposed action?
c,Are any pedestrian accommodations or bicycle routes available on or near site of the proposed adioan.?
'.loess the proposed action meet or exceed tlue stag energy code requireme: J l I
If the proposed action will exceed requirements,describe design features and teclurnologies.
El
10. Will the proposed;action connect to an existing public/private water supply? pwl 147
If No,describe method for providing potable water:
I 1. Wil I the proposed action connect to existing wastewater utilities? NO 'D`E'S
if No,describe tnethod,for providing wastewater treatrnerut;�
E3 EJ
12, aa.Does he site contain a structure that is lusted on either the Mate or Natioml,Register of Historic NO YES
b, is the proposed action located is an archeological sensitive area`o
I�
13.a.Does any portmn.ofthe site wetlands or other w�at tidies regulated
lu daction,or la nds a fbderal state oradjoining the proposed action,contain ff
y local agency" I I'll,
b. Would the:proposed action physically alter,or encroach into,any existing wetland or' aterbody?
If Yes, identify the wetland or ww+ateTbody and extent of alterations in sgoare feet or acres
14. Identitify the typical babitait types that ocour on,or are likely to be found on the project site, Check all that apply;
®Shoreline 0porest Agricultural/grasslands OEarly mid-successional
El Wetland D Urban, 'SuubunrNrt
15. Does the site of the proposed action contain any species of animal,or associated habitatsq,listed. NO VFS
by the State or Federal government as threatened or endangered?
16..Is the project site located in the l00 year flood plainu _*Fs
1 it l flue proposed,actioau create storm water discharg „either from point or no,,n- oinnt sources? YES
I f Yes,
a. Will storm water dish hares flow to adjacent properties` YES,
b.Will storm water discharges be directed to established conveyance systems runoff and storm drains)?
If"Yes,briefly describer [DYES,
Pae 2 of