Site Plan Application ....o �.; ki�y m. �y � ,
TOWN OF QUEENSBURY �� �; �� ., � r�� ,
B
Site Plan Review Application � 7
PLANNUN Off' 1C
ReviewProcess-1
1. Required Pre-submission meeting with staffto determine general, completeness ,to be bLldno later than, 1
Week prior to, deadline day, Call 1 ) 76 1 8265 or 618'x°761-8220 for an appointment..
;. Submittal of complete application: t original and 14 copies of the application package by monthly deadline.
3. Determination n of application completeness. All necessary information must be provided .and appropriate
fee(s)paid fen°eorrsiderati rr for placement on an agenda for that month.
nth.
. Incomplete applications will not be considered for gtacement on any agenda until all missin
information has been submitted.
5. Submittal to Warrent Chanty Planning, if applicable.
. Planning Beard nneetinn ,, generally the third & fourth Tuesday of each mouth. You will 'fie advised. i
writing as to which meeting to attend,.
,. Following the meeting you will be provided with a copy of the resolution stating theBoard's, decision on
your. application., if your application was approved, the next likely step is a Building Permit. Final
drawings utast be provided for the next phasc of review. if your application was denied,your project cannot
proceed as submitted..
DOCUMENTATION REQUIREMENTS (hard copy & electronic):
Please submit I orl inai& 14 conies oft the completed application,page to include:
* Completed Aaalieat ons pages 2-9, signed & dated.
Pre-Submission Meeting Notes: signed by staff
o Copy of Deed
Checklist & Plait Pla.
Environmental Assessment Form,,for any non-residential project
+�
Fee: 10 -- 1 Q,0.00 sq. . S.250 (10,001 — 30,000 sq. . $500 ,001 100,000 . .); 1,000
(100,000+sq, ,'
Staff& Contact Information:
Craig,Brown, Zoning Administrator eraigb(i4aueensbury.net
Laura Moore,Land Use Planner ImooreAqueensbua.net
Sunny 1weet, Office pecialist—Planning snnnn s uee nsbrr ,rnet (51,S),761,8120
Visit enrr w6bsite,at . rreensbp snot for further information and forms
Site Plan Review application—Revised October 201
Tow of QueensbuTy Flaming e-7 iBay Road,Queensbury,NY 12804
General Informat,1011
Tax '"arced ID Numbu: 0_)� , 5—I —
Zoning District
Loi size:
mt d ,use']
Detailed Description of Project i� des cu����
� h
�. �
�"
Location of prof t.
AIJ VII
Applicant Nees: Addr :
,
Home Phuoon
Work Phone F'ax
E-Mail:
Here Phone COL.
'!dor,,Prue Fax
F- ai
Owner°s Name Address
Home Phan ff
i
Work Phone Fax
E-mail
Site Pia Review application—Revised October 2016,
Town of Qveensbury Plaonil Office-742 Bay Road, Queensbury,NY 12804
Site 'Develppmegt Data,
Area I Type Existing,sq. ft. Proposed Total, sq. ft.
Addition sq. ft.
A. Building footprint ?7() C) 77D D
B, Detached Garage
Accessoly Struuure(�)
D., Paved, gravel or cher hard sur&Qcd area
E. Porches/Decks
F
G. Total Non-Nunimble [Add A-F]
3 �5
H. Parcel Area [43,560 sq, & /arm)
T. Percentage of Impermeable Area of Site [I-G/Iil
.Setback Requi�reme:n�ts
Area Required Existing Proposed
Front [1] Li
I ront [2)
Shoreline
Side Yard [1
Side Yard [2,1
Rear Yard [I] Li
Rear Yard [2]
Tr v 1,Corridor
Height(rnax.1
Permeability
No., of'parking spates
3
Site Plan Review application—Revised Oct6ber 2016
Town of Queensbu�ry Tannin g Office-742 Bay Road,Queensbury,'NY 12804
AdditionalTroiggt 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):
3. Does this projectreqpire coverage under the New York State Pollutant Discharge Elimination System
(SP)DES),Permit Pro ram
4. Estimated project duration. Start Date._VJ_ End Date
5. Estimated total cost of prei ect:
6. Total area of land disturbance for project; ovu-
Floor Ama Ratio Worksheet
FLOOR AREA RATIO (FAR) The relationship of building 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 AreaRatio [FAR]
Waterfront Residential WR ;0l.2 2
Commercial Moderate/Intensive C:Il�9
A. The combined area of all square footage, as measure from exterior walls of all structures on the property,
including all flolors of the structures, garages, basements and attics with more than five (5) feet of ceiling
height and covered poll 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 be included. (See "FLOOR AREA,RTI 0").
B. Commercial or induarial: the total area in square feet as measured from the exterior of the outside walls of a
bu,ilding or structure, and when applicable, the sum total, of all floor area of the principal and acce, ssory
buildings or structures on the project site.
A. Parcel Area
B. aciu tlrr, to r urc1, ft. [see above d4niti !rrJ
C. ProposWXddidonal fl,�or_A,iWo sq. fl,.
D. Proposed Total Floor Area ft
E.1,1111111.11otal Allowable Floor".Area (Area.xr gee above tablel
*If D is larger than E. a variance or revisions to your plan may be needled. Consult with Staff,
4
Site Plan;review appi ication --Revised October 2016
Town of Queen*lury Phinning Office-742 Bay Road,Quee-asbury,NY 12804
§ 179.9-080mmumts fb,r Site Plan Approval.
The Planning Board, shall not approve a Site Plan, unless, it first determines, that sucti site plan meets the
following Standads, Please p'uepare responses to caeb of the following topics:
STANDARDS
A
'The proposed project furthers or is consistent with the policies,of the Town's Coulprehensive,Plan,
B 1h proposed project complies with,0 other requirements of this Chapter,including 0W We plan review standards as set fb�rth in Paragraph
F of this section,,the dfinemsional,bulk and density regulations of the zoningdistrict,in whichit is proposed to be located(Arti�cle 3 and
Table 1) the applicable requirements ofall other.Articles that apply,
C. The site plan entourages pedestrianactivityinternally and, if praoticable,,to and from,the site with pedestrian paths or sidewalks connected
to adjacent areas,
D. The site plan must conform to Chapter 136,Sewage and Stwage Disposal,Chapter 147 Storrawater Management Local Law,and 71—ei—
applicable local laws.
...........
E. The proposed use shall e in harmony,with the general purpose or intent of this Chapter,specifically taking into account the:location,
character and size of the bproposed 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 witli dle proposed use and the nature and rate of any increase in the burden on
supporting public services and facilities which will follow the approval of the proposed use,
F. The establishment,maintenance and operation of the proposed use will not create plublit hazards from txayffic,.traffic conation or lite
parking of velAcles arldfor equipment ori be otherw&detrimenm1to the health,,safety or general welfare 017persons residing or working in
the neighborhood or to the general welfare of the town. Traffic access and circulation,road inter�sicetions,road and driveway widths and
traffic controls will be adequate.
(j7 Off-street parking and l9oading faci titles wi I]be appropriately located,and arranged and sufficient to meet traffic anticipated,to be generated
bythenewuse. The establishmentof vehicle links between parkingareas ofadjacent properties are pro�vided where feasible. Thisfurthm
ft Town's goad of reducing curb cuts and reducing congestion. A Menty-foot wide connection is required. If adjacent properties are either
undeveloped or previou sly developed without having made provision for future linkagc,then a future connection must be identified and
provided for in the site plan under review for such.future,linkage,when the time arises, The Planning,Board may require proof that the
applicant has made contact with adjacent properly owners for purposes of coordinali linkagcs with adjacent properties.
H. The project shall not have,an undule adverse import upon the natural,scenic,aesthetic, ecological,wildlife,hWoric,recreational oropen
space resource,-,of the town or the Adirondack Park or upon the adequate provision of supporting facilities and services made necessary by
the project,taking inloaccount die commercial,industrial,,residential,recreational or odder benefits that might be derived trom the project.
In making the determination hereunder,the Planning Board shat I consider those factors pertinent to the prcj,ect contained in the
development considerations,set fbrth herein under 179-'9-090 of this Chapter,and in so doing,the Plann Ing.Board shall make a net over!ao
evaluation of the,project in relatioll to,the development objectives and general guidelines set forth in J, 179-9-080 of this Arficic-
The provision for and arrangement of pedestrian traffic access and circulation,walkway structures,control of intersections witWvchicular
traffic and overall pedestrian convenience shall be:safe and adequate for pedestrian movernent. Pedestrian connectibns between adjacent
sites shall be provided to encourage pedestriaa use.,
J. Stormwater drainage',facilities will prevent an increase of post development drainage flows as oompartd,to pre-developl-neat drainage flows.
Drainage of the,site sbAl recharge ground water to the extent practical. Surface waters flowing off-site shall not degrade any streams or
& J'
adversely affect drainage on.adjacent properties or public m. ad "acititiesshal I be in conformance with the drainage standards of Chapter
147 of the Town Code and time.Town of'Queensbury'Subdivision Regulations whereapplicable.,
The water supply and sewage disposal facilities will be adequate:and will meet all applicable and current requirements set fonh by
Department of Health regulations and Chapter 136 of the'rown Code.
L The adequacy,type and,arrangement of trees,„shrubs and other suitable plantings,landscaping and screening shall effic-ilvely—provide a
visualft,an&or noise bubetween the applicants and adjoinfLi
adjoining lands, including the maximm,retention of existing vegetation and
maintenance, includ in&replacement of dead or deccamd plants,
M. Fire lanes,emergency Zones and ire luydrants will lme adequate uuund':ruueet flue needs anwd r�qunlrerrneauts of emergency service p];rraviders.
The design of structures,roadways and la,nd,s�caping In areas susceptible to ponding,flooding and/or erosion 'I mt, void such
impacts,to the maximum extent practicable.
0. The she plan-conforms:tio,the design standards,landscaping standards and performance;standards of this chapter. —
5
Site,Plan Review application—. evised October 2016
Town of QueensbuTy Plan ning,Offiee-742 Bwar Road,Queensbury,NY 12804
§ 179-9-050 Checklist-Application fo,r Site 'Plan Review.
Application ritalerials and site plan shallinclude sufficient inti cirmation for the Board to review and provide a
decision. The: applicant is,to proy a site plan drawing and all attachments that address items A-V, The
site P,
�- . _ i&�
applicant mayrequest A�Ver�from�AV a�- is to provide reasons for waiver(s) requested. Please label
in,fomiation to be,,i!�,='
pi e
IRE 15VI—RE ME,NTS
A. A vicinity map drawn at the scale that shows the relationship of the proposal to existing community fhGHitF _;9ti0h_of A
or serve it,such as roads,shopping areas;,Schools,etc., The map shad also show all properties,identifowner's, C V
�subdivisions- streets and casements within 500 a feet of the property. Such sketch may be superimposed.on.'a.United States
Geologictal ,curve y map of the area,
B. Ilie site plan shall be drawn at a scak,,of forty,feet to the inch(I"=40 feet)orsuch other scale ms the Planning Board may
eern appropriate,on standard 2 "x 4 36"Sheets,with Continuation on.�S V2"x I I"sheets as necessary for written
11nfarmation. The information listed below shall be showqSn jh(Lsitpsheets.
pL
Name of the projeMboundafics,date,r)orth arrow,and scale of the plan.
D. Name and address of the owner of record,developer,amid seal of the engineer,architect or landscape architect. If tile
applicant is not the record owner,a letter of authorization shall,be required from the owner, FT�
E,, The location and use of all,existing and proposed s,truct�ures within the property,including all dimensions of height and
.floor cation
exterior entrances,and all anticipated future additions and alterations.
F. 'The location of al I present:and proposed publicand private,ways,,off-street parking areas,driveways,outdoor storage areas,
sidewalks,ramps,curbs,paths,landscaping,walls and fimces, Location:,type and screening details for all wastc disposal
containers shall also be shown.
C'T
The location,height,intersity andbulb type(sodium,incandescent,etc.)of all extol lighting fixtures, The direction of
illumination and methods tocliminate glare onto EDd" es must also be shown insRMI 20 Qijr-'41 16
H, The location,height,size,materials and design of all proposed signs. luo C koqtj e>
The location of all present and proposed utility systerns including.
1, Sewage or septic systwn,;
2. Water supply system,
�3, Telephone,cab e and electrical systems,and
4. Storm drainage system including existing and proposed drain lines,culverts,catch basins,headwalls,endwalls,
hydrants,manholes and drainage swales,
�Tplants to prevent the pollution of surface or groundwater,erosion of soil both during and after,construction,excessive runoff
and flooding of other properties,as applicable. A Stonriwater Pollution Prevention Plan(SWPPP)for all Land developtrient
activities(excluding agricultural wivities)on the site that resultsin land disturbance of one acre or more. A SWP.IIP shall
comply with.the requi rements of the DEC SPDES MS-4 General,Permit and Chapter 14'x'of the Town of Queensbury
Code. It shalt be at the discretion of the:Planning Board as to whether a 9WPPP or an erosion and control plan shall be
required for a site plan mview project land disturbance ofle&q than one acre-
K Existing and proposed topography at two-foot Contour intervals,or such Ge
er contour intmal as the Planning,Board shall
allow. All elevations shall refer to ffic nearest United States C'=tat and odetic Bench Mark- If any portion of the parcel
is Within the I00-year foodpi ain,the a=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 approimate
volume in enbic yards.
llauutdso plan showing all existing natural land features than may influence the design ofthe proposed use swh as ro&
outcrops,stands of trees,single trees eight or more inches in diameter,forest cover and water sources and all proposed 6"1' Y2
changes to these features,including sizes and types of plants. Water sources include ponds,lakes,wetlands and
watercourses,aquifers,floodpJains and drainage retention areas.
Land Use District boundaries within,500 feet of the site's perfinmr shall be drawn and identified on the site plan,as well
as,any Overlay Districts that apply to the property,
Sits Platt Review appliCatioln -r Revised October,2016
Town of Queensbury Planning Office-742 Bay Road:,Queerisburry,NY 128104
REQUIREME NTS (CONTINUED) siy'0 et#
I N, Trafric flow pattc7�i,Ziehin'tEi r site,entrances and exits,loadingand,unloading areas,as well as curb cuts on the site and
within 100 feet of the sile� Tlie Plenning Board may, at its discretion,require a dctalled traffir study for large developments or
for those in heavy traffic area, which.shall include: 1'
0
1. The projected nurnber of motor vehicle trips to,enter or leave:the site,estimated for weeklyand No'nQ 03
annual peak hour traffic levels, , V
2. The projected traffic flow pattern including vehicular movements at all m*r intersections likely C'C t ng
to bc affected by the;proposed Use of Clue she",
3. The Impact of this traffic on levels of s miet on abutting public streets,and at affected
intersections., Existing.and proposed weekly and annual peak hour traffic levels and madcapacity
levels shall also be given.
0. For new construction�OT altcTations to,any structure,a table c�yrvtalning the following infoffnation shall,be included:
I. Estimated area olf structure to be used fbr particular purposes such as rctain operation,office, ed,
Storage,etc.; D
2. Estimated maxi rnu m number of employees;
3. Maximum,scati ng capacity,where applicable,and
4. Number of pafkIng spaces existing and required for the intended use.
P I. ROOT Plans.
2. Elevations at a scale of one-quartcr inch equals one toot(1/4r=I fh0t)for all exterior facades of the proposed structuTC(s)
and/or alterations to orexpansions of existing facades,,,showing design.features and indicating the:type and color of materials
to be used.
Q. Soil logs, water supply wel'I and,percolation test results,and,storm water runoff calculatiorts as needed to,determine and E)
mitigate project impacts. C61 lz'qca!�
R, Plans for disposal of construction and demolition waste,either.on,site or at an approved disposal Wlity, 51 te'llot CIJ�
Plans for snow removal,including location(s)of on-site snow storage, C"5ium
nil, A Noc" -19-Crlp
T, An Environmental Assessment Form("EAF")as required by the SEQRA regulations,with,Part I completed b�y the Applicant
shall be subirnitted as,part,of the application. If the proposed projectrequires a special use permit and an EAF,has been
submitted in conjunction with a special use permit application,a duEAF no
plicate is t required for the site plan application.
U. If an application,is for a parcel or pucets on which more than one use is ImWosed.the applicant may subrait a single
application for allsuch uses,,provided the proposed uses am accurately dc]incated on a site plan drawn pursuant to the
requirements set forth above, The Planning BQWmay grant the application with respect to some proposed uses and not ocf
others. For purposes of reviewing an application(and for'SEQRA complian.ce)611 proposed USES on a single parcel or on
contiguous par-cels,shall be considered together.
A brief nam. tive statement on,how the project proposed for review furthers or is consistent with the vision,goals and Policies
in the TowW's Comprehensive Plain.
7
Site Plark.Roview application—.Revised October 2016
Town ofQueensbury PlanniiagOfftee-742Brig Road„Q,u.e:e,,nsbaTy,,NY 12804
Town of QueensburySite Plan Pre-Submission Conf r enc dorm / Section 1799
1. App1jeaut Name: c(I 5
., Tax Map 1 l -50 lir otionc
t
., Zoning Clas tiicatiorr
,0W\ G c
,. Zoning Section
C. Pre-Subm, is ion I! ee irn: dotes: Provided) Outstanding- Plessrr provide by
)Do
orneral Information rrnpl t
Sitc Mvd p not Data ompl t
Saback Rquirements Complete
Additional Projeet lrnfr•nation CompWte,
FAR addressed
Regpirernnernts for Site Plan-Standards
Checklist items address
EnvironmentalF'ornrn completed, m..
u ' Pqr �
k 4, C wc
�I nsec, t
L ec, ' "' .
Sitaff Representative: Llcv
V,Appficant/agent: Date, & � �(
8
Site Plan levier pplii�atiaa,--Revised October 20 i
Town ofQueens ury Planning Office-742 Bay Bead,Queensbury,NY 128014
signature: Page
This, page includes the L) Authorization to Act as Agent Form: 2.), Engineering Fee Disclosure, 3.) Authorization for Site Visits; d.)
Other Permit Respons'bilifies;&) fficial Meeting Disclosure and 6.)Agreement to provide documentation required,
OWNER'S ACENT FORM'
Complete the following,if the OWNER of the property is,not the same as the applicant
ownor
l�sigaates-
As agent regarding. Variance -Site Platt Subdivision
Por-rax Map No.. Section -Block �Lot
Deed.Reference. Book Page Date
OWNER SIGNATURE. DATE:
APPLICANT's AGENT,FORM.
Complete the following,If the APPLICANT is,unable to attend ft meeting or wishes,to be represented by anotheer party:
Owner:
Designates:
As,agent regarding- Varian ite Plan Subdivision
For Tax Map No- Section Mock Lot
Deed Refeivitce: Book Page Date
SIGNATURE: DATE.
2.1 Applications may be referred to the Town consulting engjoecr for review of septic design, storm
drainasc, etc. as detennined,byr the Zoning or Planning,Department. Fees for cnSinecring review services will be charged directly to the applicant.
Fees for engincering review will not cxceed$ 1,000,without notification to the applicamt.
3.1 AUTHORIZATM FOR SJU-Vt$11S. 'y signing this page and submitting the applicai ion materials attached herein,the Owner, Applicant,
and h iO,critheir anger gS)hereby authorize the Zoning Board or F1 anning Board, and Town Staff to enter the subject propertiesfor the purpose of
reviewing the appi icadon submitted-
4.1 OTHER PERMIT RESPONSIBILITIES- Other penTnits may be required for construction oralteration activity subsequent,to approval by the
Zoning Board or Planning Board, It is Ole applicant's responsibility to obtain any,additional pennies.
1) TICIAL MEETING MINUTES DISCLOSURE. it is the practice of the orruruuuanity Development. Department to have a &signaled
stenographer tape record the proceedings of meetings resulting frorn application, and minutes transcribed from those tapes constitutes the official
record of all proceedings.
6j, AGREEMENT TO PROVIDE DOCUMENTATI.ON 9FA20RE : 1,the undersigned:,have thoroughly read and understand the instructions
for subralsslon and agree to the submission requirements,I acknowledge no consiructi on activities shall be cornmenced prior to issuance ofa valid
permit. I certify that theapplicati6n, plans and supporting,materials are a true and oomplete statenlent/description of the existing conditions and the
work proposed, and that all work will be perfoTmod 'in accordance with the approved plans and in confonTlance with localzoniAg regulations. I
acknowledge that prior to occupying the faci lifles proposed,I or my agent%wil I obtain,a certificate of occupancy asneecssary. I also understand that
11we Tnay be required to provide an,as-built survey by a licensed land surveyor of all newly constructed facilities prior to issuance of a cenitricate of
occupancy
I have and ajree 7to ecualaov
r1gn'WyK-[Aj0IiQintI Print Name [AppI icant] Date,signedi
Signature [Agent] Print Name. [Agent] Date,signed
9
Site Plan Rei ie rw application-Revised October 2016
I I own of Queensbury Planning Office-742 Say Road, Queensbury,NY 12804
Shorl Environmental Assessment roan
P011 - Ptoject Information
Instructionsfor Com,12leting
Part I - Project Information. The applicant or project spansol,,is responsible for the completion of Part 1. Responses
become part of the application for approval or funding,axe Subject to public review, and inay be subject to fwther verfficatilon.
Complete Part I based on inion natoro currenfl'y available. If addifiQnal resinrch or investigatiQn would be needed to fully
respond to any item.please answer as thioroughly as possible based on current information,
Complete all )terms in part 1. You may also provide any additional information which ytyu believe will be needed by, or usefid
to the lead agency; attach addi6onal pages as,necessary to supplement any item.,
Part I - P'rqjed and Sponsor Infolrm,nflon
Name of Action or Project.
51� D
Project Location.(desuibe, and attach a locationt��
Map
Brief Description ofPropiolse nlActiom
, 4 A 0 k'�-*'t e,,
6jn�
Name of Applicant or Sponsor: Telephone-
E-Mail:
Address, mm
City/po: state, Zip Code.
1.Does the proposed actiononly involve the legislative adopitioln of a plan,local; law,o—irdin—is-nte, NO YES
admin[stradve rule:,or regullatioli?
If Yes,attach a narrative:description of the intent of the proposed action and the environmental resources that
may be affected in the municipality and proceed to Part 2. Lrno,00ntinuetoqucstiQnZ
�2, Does the proposed action requ ire a permit,, approval;or funding from any other governmental Agency? NO —VES;
if Y,-s,I ist agewy(s)name and permit or approval
1-0
3.a.Totall acreage of th e sire of tile proposed action I acres
b.Total acreage to be physically disturbed? acres
c.Total acreage(project site and any wintiguous properfie,�)owned
or controlled by the applicant or project s,ponisor? acres
4, Check al I land,uses that occu r on, adjoi n ing and near,the p oposed act i
C]Urban 011ural (nan-agiculture) Ohldlustr (suburban)
El PDrest ElAgriciulture MA uuat ic E10 tber(speci fy):,
El Parkland
Page I of 3
Is the proposed action Y ES C .
a- A permi'tted use under the zoning reguIations?
LJ
b,.Consistent ww^ith the adopted comprehensive plan?
6. 15the proposed action consistent with the predominant character of the existing built car natural VE
� . ... .m
"TTS the site o�ftlhe pu'oposecl aaction located in, or docs it adjolru,a state listed riticah.Ynvironmental area? "YE' . .
lfYes, identi,� ..
8, a., Will the propulsed actizn result in a substantial increase in traffic above present leVel,s? 'YE'
b,Are punb�hic t asportation serviice(s)available at or near the site:ofthe proposed action?
L1
c. Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action?
9. Does rile prop sed action meet or exceed the state energy code requirements? N YES
lithe proposed action will exceed requirements,describe design features and technologies:
101. Will the,proposed action connect;to an existing public/private water supply? "YE
If o,describe nuuethod dor pnovi�dirtg potable water:�°
I 1. Will the proposed action connect to existing wastewater utilities? D'E'S
Ili1f too,describe method for proviadin wastewater,treatment: �� -�.
12. a. Pl es the site contain a structure that is listed oro cifter the Mate or National Register of Historic V
b.. is the proposed action located in an ardwologicaI sensitive arca"
1 , a.. Does any portion of the site of the proposed act.emn,or lands adjoining the proposed action,contain NO 'YE
wedands,or other waterbodies.regulated by a federal,state or local agency
b. Would the proposed action physically alter,or encroach into,.any existing wetland or wva rb°ody? f�
If''Yes, identify the wwcfland or vwaterbody and extent�o�falterations in square fett or acres', �l
14. Identify the typical habitat types that occur on,or are llluelly to be found on the project site. Check all that:apply;
®,Shoreline ICS Forest []Agnicultural/grassiand's Early mid-successional!
' ed'and 0 Urban 4K Suburban
t s latate or-I -
of
l ePal po chitin t as threatened d�r actiop conta in any ie f anirnal,,or�associated habhtats, listed 'O, YES
Y gered" 0
16. is the projiect site located in the 100 year flood plain? No
_ VET
17. Will the proposed action create storm water discharge,either from point or non--p"o,irnt sources?' NO Y EZ S
If Yes,
a."ilv'ill storm water discharp,,s flow to adjacent properties? Ej NO, E]YE.
b, Will stones water discharges be directed to established conveyance systcuns(mino,fFand storm drains,)?
hl""Y`es, briefly describe:. EINO �YE
Paget if 31
Agency Use 0114y [if Applicable]
Date:
Sh orl E,n Wronmen tol A ssessmew Form,
Part.2 - Impact A vvessmew
Part' is:to be co M Pleted by the Lon d Agency.
Answer all of the following questions in Part 2 using theinformation contained in Part I and other materials subraitted by
the project sponsor or otherwise available to the revIewer. When answering the cluestiorts the reviewer should be Suided by
the concept"Have my responses been reasonable considering the sealle and context of the;proposed action?"
No,or Moderate
Small to targe
impact Implact
may MAY
oiccul,
1. Wi 111 the propo-qed action create a material con flirt ct with an ado p te:d land u so plan or zmwnirm
regulations? 121
2. Wi I I the proposed action result in achange In the use or 1 ritensity of use 0,17 land? M
ill the proposed action impair the character or quality of the existing cornmunity? R1 El
4. Will the:proposed action have an knpact on the environmental characteristics that caused the
establishment of a Critical Environmental Area(CEA)?
S. 'Will the,proposed action result in an adverse change in the exisfing le:vel of traffic or
affbct existing inftstructure for mass transit, biking or walkway?
6, Will theproposed act[on cause gin,i ncrease i n the uw of energy and it falls to 1 ncor�porate
.--ie-alloraably avail,able energy conservation or renewa-bleenergy opportunities?
7. Will the proposed action,impact exisfing-,
a.publ le/private water supplies''
b.public I private wastewater treatment utilifies?
8. Will the proposed action impair,the character or quality of irnportant historic,archaeological,
architectural or aesthetic resources?
91. Will the proposed action result in an adverse:change to natural resources(e.,&, wetlands,
waterbod its,oroundwater, air q ual i ty, flora and fhu na),?
.10. Will the propostd action result in an increase in the potential rbr erosion, flooding or drainage
ptoblerrs?
JJ- Will the:proposed Action create a hazard to'CoVrironmenusl resource or huinan health?
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Agenc est:Onjlw llfa ,Hcablej
Project-.
Daw,
Short Environmental A5sassment Fw-m,
Part,3 Deterinination of Significance
Fror every question in Part 2 that was answered"moderate to large impact may occur",or if there is a need to expl.-iin wlly a
Particular ellernent of the proposed salicin may or wi R not result i 11 a S lign i Ficant adverse envi ron ments I impact, p I e;,t5e
complete Part 3.Part 3 should, in,sufficient detail,identify the impact, inClUdling any measuresor design elements that
have been 111CILIded by the project sponsor to,avoid,or reduce innpacts,. part.3 sho�uld also explain how the lean agency
determined that time impact may or wiA not be significant. Each potential impact should be assessed considering its setting,
probabillity of occurflng,duration, irreversibility, geographic scope and magnitude, Also consi&r ffie potential for short-
term,, long-terrn and cumulative Inipacts'.
Check this box ifyou have determined, based on the inforn-mflionandanalysis above,and any supporting docunmntWion,
that the proposed action may result in one or more Potentially large' or significant adverse impacts and an
an vironmental 1 rnplact statement is req ul red.
Check this box !f You have determined,eterined, based on the i0brnnati on and!analysis above,ans
d,any uppiort in docu mentation,
that the proposed action m411 not result in any significant adverse environmental impacts.
Name of Lead Agency Date
Pri n tr or Type Name,of R esponsi b I a 0 fficer in Lead Agency Title of Responsible Officer
S[gnat ure of Respansi b le OfYicer in Lead Agency Signature of Preparer(I f d i fferent from. esp nsibit Offi car)
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