Site Plan Application General Information
Tax Parcel ID Number- 226.16-1-24 D 9 FE
U
Z031irig DISti`LCt:
Ona `
Lot size; 5 Acres TOWS! OF QUEE SBURY
COMMUNITY DEVELOPMENT
Detailed Description of Project [includes current&proposed use]'
Rem_nye_seyernl white a Ereen are ton alnee M h ome bpd that nose a rack to the hone or hodily harm i f they fal l over in a starrn_
the trees are over 1 DO fcct tall and as large as 24"dianttter,with some leaning in the direction of the home,
Location 4�)f project:
55 Mason Rd
Appikarlt Nairne: Micbsel Bad= Address: 175 Broad St#238,Glens Falls,NY
Home Phone 518-656-5063 Cell- 518-796-3725
Work Phone na Fax na
1-Mail: preoisianmikc(crosrt_Cont
Agent's Name: Address:
Home Phone Cell;
Work phone Fax
E-mail
Owner's Name Address
ASI Dream LLC, Michael Badera
Home Phone Cell
Work Phone Fax
E-mail
Site Plan Review application-Revised October 2416
Town of Queensbury Planning Office-74Bay 1toad,Queensbury,NY 12804
Site Development Data
! Arca 1'Typc Existipg sq. ft. Proposed Total sq, ft.
Additions . ft.
A, Building footprint 3509 0 3509
B. Detached Garage
C. Accessory Structure(s)
I]. Paved,gravel or other hard surfaced area I 6QH0 0 600
E. Porches l Deeps
F. Other
. Total Nort-Permeable [Adel A-F] 4109
H. Parcel Area [43,560 sq. ft.l acre] 19602 19502
L Percentage of Impermeable Area of Site [i= JH] 21%
Setback Requirements
Area Required Existing Proposed
Front[1] no changes
Front[ ] no changes
Shoreline no changes
f
Side Yard [I] I no changes
Side Yard [2] no changes
Rear Y"[I] no changes
Rear Yard[2] ac changes
Travel Corridor no changes
Height [max] i no changes
Permeability 75 79
No. of garldng spaces no zhmges
3
Site Plan Review appiication—Revised 00ober 2016
T wn of Queensbury Planning Office-742 Bay[toad,Quum5bu y,NY 12804
Additional Proket Information
1. Will the proposal require a Septic Variance from the Town Board of Health?
2, If the parcel has previous approvals, list application number(s): no
3. Does this project require coverage under the New York State Pollutant discharge Elimination System
(SPDES)Permit Program ? no
4. Estimated project duration. Start Date July 2017 End Dane August 2017
5. Estimated total cost of project: SUM
G. Total area of land disturbance for project: 0
Floor Area Ratio Worksheet E
FLOOR AREA RADIO (FAR) — The relationship of building size to lot size, derived by dividing the total
building floor arca by the lot size in square feet,yielding a percentage.
Zoning District Symbol Floor Area Ratio [FAR]
Waterfront Residential WR 0.22
Commercial Moderate!Tnteasire CMI C1 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 ( ) feet of ceiling
It J&and covered porches. Building square footage 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 he included. (See"FLOOR AREA RATIO').
B. Commercial or industrial: the total area in square feet as measured from the exterior of the outside walls 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 Area 19602
B. Existing Floor Area 6611 +/- ft. see above definition
C. Proposed Additioual Floor Am 0 sq. ft.
D. Pro used Total Floor Area 0 sq. ft.
E. Total Allowable Floor Area 4312.4 area x 0.22 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
Town ofQueembury Pta ring Office-742 Say Road,Queensbury,NY 12804
179-9-08Regnirements for Site Flan Approval.
The Planning Board shall not approve a Site Plan unless it first determines that such Siw Plan meets the
following Standards. Please prepare responses to each of the following topics:
STANDARDS
A. The propmd project furthers or is consistent with the polities of the Tavm's Comprehensive Plan_
& The proper 1Pmject complies wilh all-other requirements of this Chapter,induCmg The site plan review standards as set forth in Paragraph
F of this section,the dimensional,bulla and density regulations ofthe zoning district in which it is proposed to be located(Article 3 and
Table 1),the applirablc reyuirems!tts of all other Articles that apply.
C. The site plan entourages pedestrian activity internally and,ifpmoticable,to and from the site with p4W&ttian paths or sidewalks catutected
to adjacent areas.
D- The site plan must oonform to Chapter 136 Srw-agG an curage Disposal,Cbaiptcr 147 Stormwww Managen=t Loud Law,and other
applicable local laws.
The proposed use shall he in harmony with the genml purpose er intent or this Chapter,WcWAlly taking into account the location,
aha oUz and size of the proposed use and the description and purpose of the district in which such use is proposed,the netaro and intensity
ofthe acnmo&gs to be irwolvw in ar cranduottrl in camzcetkM wilb The proposed use sod The nalture and rate OF BAY increase in the burden on
supporting public services and Facilities which will&111 wthe approvai of the proposed use, r
F. The cstablishment,maintenance and operation of Nie proposed use will not create public hazards from ,traffic cungssdA of the
Parking of ve.hiele$andlor equipa'nent or be other►wist detrimental to the health.safety or general Welfhre persons residing Of working in
rhe n6ghbodrood or to the general we]fare of the town. Traf i;aoeass and circulation,rind intersections,road and driveway widths.and
traffic oantimis will be adequate.
Cy Oft-street ping and l9oeding facilities will be appropriately located and arranged and s ient to meet tmfffe anticipated to be generated
by the now use. The establisbmcnt of vehicle links ktwcca parking areas of adjacent piup&tics are provided where fuwiblc. This furthers
the"lawn's goal of reducing curb cuts and reduemi g congesrion. A twenty-foot wide connection is required. if adjacent properties are ekher
uadtvaloped or previously davclopcd vwithout having made provision for future linkagc,then a Futuro oanncction Frust be idmttficd and
provided For in the site plan under rovicw for such future kinkage when the time arises. Thu Planning Board may require proof th e
applicant has ulsde contact wills adj awnt property owners far purposes of coordinating linkages with adjacent properties. w4j.
H. The projuct shall not have an undue adverse impact upon the natural,scenic,ansthedc,eeulogical,wildlife,historic,rcoreatiannl m
space resources ofthe town or the Adirondack Park or upon the adequate provision ofsuppmrting facilities and services made necessory by
the project,taking into account the cmmmcroial,Industrial,residential,m rcational or other bcnctits that might be derived from the project.
In making the determination hereunder,the Planning Board shall consider these factars pertinent to the project contained in the
development considerations set R tth herdn under§ 179-9-080 of this Chapter,acrd to so doing.tktc Plmoing R*ar i shall mince a act wool l
evaluation of the project in relation to the development objectives and general guidelines set forth in§ 179-9O of this Article.
I
The provision for and arrangement of pedestrian TrAf 3V access and cireal ation,w.rl&way structuress,omtrel of intersections wish vehicMar
nfflic and overall pedestrian ronvenicnee shall be safe and adequate for pedestrian movement. Pedestrian conn Lions bctwrcn adjacent
sites shall be Provided To to ODUr rgo pedestrian use.
J Stormwiater drainage facilities%will prevent an increase ofposl development drainage flows as compared top evelopment drainage ffows_
Dmihage ofthe site shall recharge ground waltr to the"tent praelical. Surface wutcrs flawing ofd site shell Mt drgradc any stria
adversely affect drainage en adjacent properties of public roads_ Facilities s1sa1€be in conformance waNr the drainage sterrdardsI to
147 ofthe Town Code and the Tolr%n ofQuwnsbury Subdivision Regulations whurc appl"blc.
K. The wEiter supply and sewage disposal fackEitics will be adequate and wilt meet all applicable and current rzquiramcnts sct forth ,
Department of Health reguiations and Chapter 136 ofthe Town,Cndt_
L. The n*uaoy,type and w mgerprnt oftr"s,shrubs and ACT suitablt plamticgs,landscaping rind screening C41 effectively provide a
visual andlor noise buf6er between the applicants and adjoining lands,including the maximum retention of existing vegetation and
Madntenorrce,includingmplarcmut of dead or deceased plants.
M- Fire]ones,emergency zMes and tiro hydra ntb will be atdcquate and mact the needs and r cquiTamcnts of MVInry servioe providers
. The design of struehdes,TeAdways and lonawaping in arey5 susccptibic to ponding,flooding andr'ar crasi�n will mini avq u
impacts to the maximum extant practicable. l
Tho site plan conforms to the design standards,landscaping standards and performance standards mf this chapter,
S
Site Plan RL-view applioaflprr—RevisedOctnber 2016
Town of Queensbury Planning Office-742 Bay Road,Queensbury,NY 12904
§ 179-9-050Checklist-Application for Site Plan Review.
Application materials and site plan shall include sufficient information for the Board to review and provide a
decisiDn. The applicant is to provide a site pian drawing and all attachments that address items AN. The,
applicant may request a waiver from AN and is to provide reasons for waiver(s) requested. 'lease label
information to be submitted.
RE UMEMMNTS Shut
A. A vicinity map dmvpn at the scale that shows the rclatiamhip of tha pmpmaal to existing community facUitics which affect
or serve it,such as roads,shopping eras,schools,etc- Tho map shall also show al l properties,identify ov mers, na
subdivisions,streets and ca_scments within 500 feet of the property. Such a sketch may be superimposed on a Unitcd States
Geological Survey nup of the=a-
B.
re$B. 7 be site plan shall be drawn at u scale of Fort) feet to the inch(l"=40 frit)or such other scale as the Pjwming Board may
deem appropriate,on standard 24"x 36"sheets,%%ith continuation on 91!2'X€ 11"sheets as necessary for%witwn X
information. The information listed below shall be shown on the site plan and continuation sheets-
C.
Name ofthe prodect,boundaries,date,north arrow,and scale of the plan.
X
D. Name and address of thu owner ofrccord,developer,and seal oftbc engineen architect or landscape architect. Ifthc
applicant is not the record owner,a letter of authorization shall be regulfed from the owner_
E. The location and use of all existing and proposed structures within the Property,including ell dimensions ofheight said
floor area,all exterior entrances,sold aii amici sled facture Additions Aftd alterations.
F The location of all present and proposed public"Private ways.off-stm;t parldng areas,driveways,outduor storage tucm5
sidelrvalks,ramps,curbs,paths,landscaping,walls and fences. l.:ocadon,type and screening,details fof all waste disposal
containers shall also be shown-
G. The location,height,intensity and bulb type(sodhlN,incandescent,etc.)ufall external lighting fixtures. The direction of
illumination and methods[o eliminate glare onto a4joining jimperties.must also be shown in caro lianoe with§ in-&020_ ina
H. rhe 10ca0n,height,size,materials and design of all proposed sigts, Ila
j The location of all present and proposed uWity systems inatuding= x
I. Sewage or septic system;
2. Water supply system;
3. 'telephone,cable and electrical systems;and
4. Stofm drainage system including existing and proposed drain lines,culvmU cotch basins,headwalls,endwalls,
h'vd=M,m"boles and drainage swalca.
j Plmis to prevenr the pollwio a or wfte or g oundvmler,erosion of soil both during and after construction,exomsivc runoff
sold flooding of other properties,as applicable. A Starinwater Pollut on Prevention Clan{SWPPP}for all land development 11a
aotivities(excluding agricuifural activities)ca tht site(hat results in land dikurbmr&ofanc acre or mare. A SWPPP shall
wmply with the requirements o f the DEC SPDES MS-4 Cktwml Permit and Chapter 147 of the Town of Queensbury
Coda It she!)be a the discretion of the Planning board as to whether a SWPPP of an erosion and control plan shall be
requited for a site plan review project l stud disturban cc of less(ban ono acre.
K. Existing irnd proposed topograpby at tvtx4bot contour intervals,or such other(amour interval as the Planning Boao shall
allow. All elevations shall refer to the nearest United States Coastal And Gwdeiie Bench 1+f ark. If any portion of the,parml n
ar
is within the IM-year floodplain,the W=will be sho�%Tn and base flood elevatimis given. Areas shall be indicated within
the praposcd site and within 50 feet of the proposed s ite where soil removal of filling is required,showing the approximate
volume in cubic yards,
A Eandswpe plan showing all cxistfng nahoml land Features than may influence the design of the propcmd use such as ruck
outcrops,stands of trees,single trees eight or more inches in diameter,forest ces Inver and%Zer sourand all:propmed x
changes to these features,including sizes and t}pes of plaftts. Witter sources fncludo ponds,lakes.Wetlands and ;
wataraaurscs,aquifem,floodplains and drainage retention areas.
M Land Usc District bmmdaries within 500 feet of the site's perimeter shall he drawn and identified on the site plass,as well
as any overday Districts that apply to the property.
6
Site Plan review application—Revised October 2016
'rem of Queensbury Planning Office-742 Say Road,Queensbury,NY 12804
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Map Is for GENERAL REFERENCE ONLY,
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Printed 611912017 1 : 994 Page 1 { 1
REQUIREMIENTS (CONTINUED) Sheet
N. Traffic flow patterns within the site,entrances and exits,loading and unloading areas,as vmll as curb cuts on iha sib arks!
Mithin IOil felt of the fit,- The Planning Begird may,at its diserafta,require a data!led traffic study for large developments or na
far[hose in heavy traffic areas,which shall include.
1, Thi;projected number ofrnmtor vchidc trigs to enter or leavo the site,cstimaled for weekly and
annual peak hour traffic levels;
2. The projected traffic flow pattern including vehicular movements at alt major intersections likely
to be aMead by the proposed use of the site;
3. The impact of this traffic an levels of service on abutting public streets and at affected
intcraections_ Existing and proposed weekly and annual peek h=traffic levels and rand caparity
Immis shall also be given.
p For stew=Sfi%l0on or elterdtioris to arty structure,a table omtaining the foll0►ving in formation shell be included,
ltd
I, EStimaW area of stnwe to be used for particularpugxwes such es retain opmt.ion,of lea.
Storage,etc.;
2. Estimated maximum number ofemployees;
3. Maximum seating capacity,where applicable;and
4_ Number ofparldng spaces exdsdng and required for ehe intended use_
p, 1. floor Plans,
na
2. Elevations at a scale ofone-quarter inch equals one foot(IA"= 1 foot)for all exteriof facades of the proposed struchus(s)
and ur&iteration a W or expansions of existing facades,showing design features and indicating the t vpc and color of materials
to be used.
Q. Soil logs,water supply well and percolation test results,and storm water runoff calculations as needed to determine and
xttiligOtC proleCt iMPRCtS. na
R{ Plans for disposal of construction and demolition waste,either on-site or at an approved disposal facility. na
Plans far snow removal,including loprtinn(s)or ark-site stow surage. r1a
T- An Environmental assessment Farm CTAF)as mcluircd by the SEQRA rcVlations,with Pari I carnpleted by the Applicant
shall be submitted as part of the application_ If the proposed project requires a special use pernvt and an EAF has been na
sulxrdtted in corJunelion with a spcciat use perrnit application,a duplicate EAF is not rcquircd for the site plan appiicadorl.
U. if M application is For a parcel Or pa=ls on which more than ane use is proposed,the,applicant may Submit a single
applk-ation fear all such uses,provided the proposed uses are accurately delineated on a site plan drawn pursuant to die na
requirements set forth above. The Planning Board may grant the application with respcc#to samr proposed uses and not
others. For purposes offevie Mng an application(and far 5E.QRA compliance)all proposed uses on a single parcel or on
wnt gwas parcels stroll be considered together.
A brief narrative statement on haw the project proposed for review"m or is owLsistem with the vision,goals and policies
in the Town's Comprehensive Plan. x
41eea-4 /U& /U,,L-- ','— 7
7
Site Plan Review application—Reviscd October 2016
Town of Queensbury Planning Office-742 Bay Rowel,Queensbury,NY 12804
�4 i s t
Town of Queensbury Site Flan Pm-Submission Conference Form 1 Section 179-9-040
1. Applicant Name.• Michael J.Bsdera
2. Tax Map ID 226.16-1-20 Location: 55 Mason Rd
3. honing Classification resideat al
+4. Reason for Review' m moving vegetation within 35 feet Of high water mark
5. Zoning Section#. C S() L''k l r1 � 4 r� r- Z1 >
6. Pre-Submhsion Meeting Notes: Provided Ontstanding; Please provide by
Deed
General Information complete
mite Development Data Complete
Setback Requirements Complete
Additional Project Information Compiete
FAR addressed ,
Requirements for Site Plan-Standards
Cbeckl ist urns addressed LL1 A f
Environmenrtal Form completed
Signature page completed
u o N C e-4
A:Ep ' tLC_ e tn s i r(c, ret,
eU h e, 01 cam, D LU kI r
trc
na r, f ' T 4 1
Staff Representative: laurc M --
Applicant!Agent: Bate: {
8
Site Plan Review apps icadon—Revised October 2016
Town of Queensbury Planning Office-742 Bay Road,Queensbury,TAY 128Q4
Signature Page
This page ino]udes the I.) Authorization to Act as Agent Form, 2.)Engineering Fee Disclosure;3.) Authorization for Site Visits; 4.)
Other Permit Responsibilities; 5.)Official Meeting Disclosure and 6.)Agreement to provide documenWion required,
OWNEWSAGENT FORM:
CDmpiete the following ifthe OWNER of the property is not the same as the appiicant
Owner: M Dream LLC
Designates: Michael J.Badera
As o,gent regarding: Variance X Site Plan Subdivision
Pot T Map Se(60n Block Lot
Deed fteferert ok Page Date
OWNER SIGNATURE. ��''—� DATE: -0 f 12017
APPLICANT'S AGENT FOPM,
Complete the following if the APPLICANT is unable to attend the meeting or wishes to be represented by another patty:
Owner:
Designates:
As agent regarding: Variance Site Plan Subdivision
For Tax Map No., SectiDn Block Loi
Deed Referefiee: Book Page Date
p'4"ER SIGNATURE: DATE:
2.1—ENGINEERING FEE DISCLOSURE, Appli tions mo lac refined to the Town crmsulting engineer for review of septic design, storm
drainage,eW. as determined by fhc Zoning or Planning Department, Fees far engineering review smyioes will be charged directly to the applicant.
Fees for engineering review will not exceed S 1,000 without rootifrCo6on to the applicant,
3.1 AL'f HQRjZA' J(W FOR SITE VISITS: By signing MIS page,and submirting tht application materials atlachcd herein,the Owner,Applicant,
and hisAMertth6r agent(s) hereby withorizo the Zoning Board or Planning lioard and Tawe Staff to enter the subject propeaties for the purpose of
mviewingthe applicadon submitted.
4.) OTHER PERMff RESPONSFELIT1ES: Othef pmnits may be fequired for constmelion or alteration activity subsequent tp approval by the
Zoning Beard or Planning Board_ It is Lire applicant's respppsibil sty to obtain any additional permits,
Q OEPICI_ L,MEETING MINUTES DISCLOSURF= it is the pTm6ce of tho Community Development Departracnt to have a designated
stenographer tape record the proaecdings of mccdrLp resulting from application,and minutes transcribed from those tapes constitutes the official
rewrd of all prortecdings.
5.1 AGREF.HFNT TO PROUD- D-OCll;4 ENTATIQN REOULRCOM: I,the undersigned,have thoroughly read and understand tho instructions
for submission and agree to the submis"requirettten%l acknowletigo no ounsbrucfion activities shall be commenced prier to issuance of a valid
permit. 1 ccrfif}-that the application,plams and supporting materials are a true and complete statem"Wese46031 of tht existing conditions and the
work proposed, and that all work will be performed in a0 rdancc with the approved plans and in aanformance with local zoning regulalioris, I
acknowledge that prior to occupyigg the facilities proposed,i or my agents,will obtain a certificate of occupancy as necessary. 1 also undemtpnd that
Uwe may be required to pmvide an as-bUL survey by a licensed land surveyor of all riewly oomstmoA ftta lilies prior to issuomm of a ccrtifieate of
occupancy
X
read and7—r
ee the above.
t Michael J.Badem 0611812017
Signature [App]it;Wj Pratt Nee[Applicant] Date signed
ignatute [Agent] Print Dame[Agent] Date signed
Site Pian Review apps imtion—Revised October 2016
To-An of QucensWry Planning Office-742 Bay Road,Queensbury,NY 128N
,short Environmental Assessment Form
Part I - Project Information
Instructions for Comuletin
Part 1 -Project Information. The applicant or project sponsor is responsible for the comple#lon of Part 1. Responses
become part of the application for approval or funding,are subject to public review, and may be subj oct to further verification.
Complete Part 1 based on information currently available. If additional research or investigation would be needed to fully
respond to any item,please answer as thoroughly as possib]e based on current information.
Complete all items in Pact 1, You may also provide any additiarml infoniiOion which you believe will be needed by or useful
to the lead agency;attach additional pages as necessary to supplement any item,
Pert 1 -Project and Sponsor Information
Name of Action or Project:
Tree RemDval
Project Location(dcsr<rribe,and attach a location map):
55 Mason Ind
Kriel'Description of Proposed Action:
see attached
Name of Applicant or Sponsor; Telephone- 518 795 3725
Mir,hael J.Bedera F Mail:
pre�isivn m;ke',�rnan,G7m
Address:
IM broa0 St 039
CityrPO= State: Zip Code. i
glerisWla raewyork 12801
I.Does tbe.proposed action only involve the legislative adaption of a plan,local law,ordinance. NO YES
administrative rule,or regulation?
I f Yes,attach a narrative description of the intent of the proposed action and the environmental resources that ❑ ❑
maybe affected in the municipality and proceed to Part 2. If no,continue to question 2.
2. Dazs tht proposed action requi re a permit,approval or funding from any other governmental Agenr y? NO YES
If Yes, list agency(s)name and permit or approval: 0 ❑
3.a.Tolai acreage of the site of the proposed action? A5 acres
L Total acreage to be physically disturbed? 0 acres
c.Total acreage(project site and any contiguous properties)owned
or controlled by the applicant or project sponsor? .45 acres
k Check all]and uses that occur on,adjoining and near the proposed action,
C)Urban ❑Rural(non-agriculture) QIndustrial [2Commercial OResidential(suburban)
❑Forest ❑Agriculture ❑Aquatic DOther(specify),
❑Parkland -
Page 1 of 3
5_ Is the propased action, NO YES NIA
a_A permitted use under the zoning regulations' ❑ VI [:Ib,Consistent with the adopted comprehensive plan? Lt ❑
6. is Lite proposed action consistent with the predominant character of the existing built or natural NO YrS
landscape's ❑
771 1
7_ Is the site of the proposed action located in,ar does it adjoin,a state liMed Critical Environmental Area? NO YES
If Yes,identify; ❑
S. a, WiII the proposed action result in a substantial increase in traffic above present levels? NO YES
L*J 1 ❑
b.Are public transportation service(s)available at or near the site of the proposed action? 1 { i
c. Are any pedestrian accommodations or bicycle routes available on or near site of the}proposed action" Ll IV/]®1
9.Does the proposed action meet or exceed the state energy code requirements? NO YtS
If the proposed actiDrL will exceed requirements,describe design features and technologies; F-1 ❑
na
10, Will the proposed action connect to an existing publiclprivate water supply? NO YES
If No,describe method for providing potable water: ❑ ❑
na
11, Will the proposed action connect to existing ivastewaWr utilities" NO YES
If lea,describe method for providing wastewater treatment: F-1 F7na
12. a.Does the site contain a structure that is listed on either the State or National Register of Historic ! NO YES
Places? ' ® ❑
b. is the proposed action located in an archeological sensitive area?
13. a.Does any portion of the site of the proposed action,or lands adjoining the proposed action,contain N 0 YES
wetlands or other waterbodies regulated by a federal,state or local agency? Q
b. Would the proposed action physically alter,or encroach into,any ex fisting wetland or waterbody? ❑
If Yes,identify the wetland or waterbody and extent of al terations in square feet or acres:
14_ Identify the typical habitat types that Dccur on,or are Nicely to be found on the project site. Check all that apply:
m shoreline W)Forest ❑AgrieulturaUgrasslands Q Early mid-successional
Q Wetland Q Urban 21 So btirban
15.Does the site of the proposed action contain any species of animal, or associated habitats, listed N O YES
by the State or Federal government a9 threatened or endangered? ❑ ❑
16,Is the project site located in the 100 yen flood plain? NO YES
17.Will the proposed action create storm water discharge,either front point or non-point sources? O 'IBES
If Yes, l�l EJa.Will s4orm water discharges�1 to adjacent properties? ❑l�O ❑YES
b.Will storm water discharges be directed to established conveyance systemsrunoff and storm drains)?
If Yes,briefly describe: IE NO L]YES
Page 2 of 3
1$. Does the proposed action include Gon5truction or other activities that result in the impoundment of NO YES
water or offer liquids(e.g,retention pond,waste lagoon,dam)?
If Yes,explain purpose and size=
19. Has the site of the Pr❑p❑sedi action or an adj aining pmperty been the location of an active or closed NO YES
solid waste management facility?
1f Yes,describe: T 11
Z0.Has the site of the proposed action or an adjoining property been the subject of remediation(.ongoing or NO YES
completed)for huardous waste?
If Yes,describe: U
C A FIRM THAT THE INFORM ATJOX PROVIDED ABOVE 1S TRUE AND ACCURATE TO THE BEST OF M
KNOWLEDGE
Applicantlsponfinr name: -- bate:
Signature;
PRINT FORD Page 3 of 3
Agency Use Only iirapplicable]
Project:;
Date:
hon EnvironmentalAssessment Fore
Part 2-Impact Assessnwnt
Part 2 is to be Completed by the Lead Agency.
Answer all of the fallowing questions in Part 2 using the inforrnatian contained in Part I and other materials snbmitWd by
the project sponsor or otherwise available to the reviewer. When answering the questions the reviewer should W guided by
the concept"Have any responses been reasonable considering the scale and context of the proposed action?"
NN or Moderate
small to large
Impact impact
may may
occur occur
1. Will the proposed action create a material oonfllct with an adapted Land use plan or zoning 1:1regulations?
2. Wil I the proposed action result in a change in the use or intensity of use of land? EI
3. Wil l the proposed action impair the character or quality of the existing community? ❑ L❑J
4. Will the proposed action hard an impact on the environmental chars Ueristics that caused the ❑ r J-1
estPb i0n=t of L
Critical Environmental Area{CEA)?
5. Will the proposed action result in an adverse change in the existing level oftraffic or ❑ ❑
a#reCt existing infiasl1ructure for mass transit,biking or walkway?
6. Will the proposed action cause an increase in the use of anergy and it fails to incorporate ❑ Elreasonably avaiIabie energy conservation or renewable energy opportunities?
7. Wil I the proposed action impact existing. j-`
a.public!private water supplies? El El
b.public/private waO�tcr Uvaotrneflt utilities? ❑ ❑
S. Will the proposed action hrt it the ehuraoter or quality of important historic,amhaeal4cal, ❑ Elarchitectural or aesthetic resources?
9. Will the pmpnW acdoai result in an adverse charip to naft" resources(e.g,vwetl mds, ❑ Elwaterbodies,groundwater,air quality,ftra and fauma)2
10. Will the proposed action result in an increase in the prrtendid for erosion,#boding or drainage El 1:1problems?
1 i. Will the prapoaed action creMe a haaautl to environmental resources or human health? ❑ ❑
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,Ageecy Use Only I I f appikablel
project;
Date:
Short Environmental Assessment Form
Part 3 Determ ina Hion of Significance
for every question in Hart 2 that was answered"moderate to large impact may occur",a if there is a need to explain whys a
particular element of the proposed action may or will not result in a significant adverse environmental impact, please
complete Part 3.Part 3 should,in sufficient detail,identify the impact,including any measures or design elements that
have been included by the project sponsor to avoid or reduce impacts. Parc 3 should also explain how the lead agency
dezrmintd.dmt the impact may or will not be significant.Each potential impact should be assessed considering its sett!ng,
probabiIity of occurring,duration, irreversibility,geographic scope and magnitude, Also consider the potential for short-
term,long-term and cumulative impacts.
ECheck this box if you have determined, based on the informrati on and analysis above,and any supporting documentation,
�J that the proposed action may result in one or more potential ly I arge or significant adverse impacts and an
environmental impact statement is required_
Check this box if you have deterrrnned,based on the information and analysis above,and any supporting documentation,
that the proposed action will not result in any sign ificant adverse environmental impacts.
Name of Lead Agency Date — —
Print or T-pe Name of R espon.5i bl a Officer in Lead Agency Title of Responsible Officer
ignature of Responsible Officer in Lead Agency Signature of Preparer(if different from Responsible Officer)
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