Application Area Variance [ZDA a raved: Se itvhtw 21 M6J
General Information
Tax Parcel ID Number. 21 (# . 16-- t - O
Zoning District:
1
Detailed Description of Project include cttrivnt &proposed use]-
Current Use: Is tMkt± TUNN OF 01JEENSBURY
COM UNI ! DEVELOPMENT
l �
Proposed Ilse' i.V G LF_ V A,vr ra+e _
Location of Project: y
App IicautName: Mailing Address
�w1GL�S d ��Ac.l� I Li 96 9
Dome Phone 5-113 2-61 3 6t City, State, Zip
Work Phone -s& I ell Phone
E-Mail: FA No.
Agent's Name: Mailing Address
Horne Rhone Cit}, State, Zip
Work Phone Cell Phone
E-mail FAX No.
GwneCs Name � Mai Iing AddresslCoa]��� o
Home Phone pity, State,Zip
Work Phone Cell Prone
E-mail FAX No,
Page I
Area Variance JZBAapproved- StplembeT 2 1 2016]
Site Development Data
Area/Type Existing sal. ft. Proposed Total sq. ft.
Additions . ft.
A. Building footprint Y
B. Detached Garage 0
, Accessory Structure(s)
tib !bF IzsF
D, Paved, gravel or other hard surfaced area --
1 � s�
E. Porches 1 Decks
F. Other
G, Total Non-Permeable [Add A-F]
H, Parcel Area [43,560 sq_ ft_1 acre]
1. Nmentage of Impermeable Area of Site []=G/H] - -
. /zj 2-LI T
Setback Rcquirgmcnts
Area Required Existing Proposed
Front Yard [1] SON 19 Q.
Front Yard (2)
Shoreline 5,01
1I
Side,Yard [1] 2-0 ,
k OQr 4 " q% L4
Side Yard [2]
Rear Yard [1]
Rcar Yard [2.] -— - -
Travel Corridor
Height [maximum]
Permeability
Number of parking spaces
Page 2
Area Variance JZBA approved- Septcmbor 21 2016]
Additional Project Information
1. Wil l the proposal require a Septic VaTi&nce from the Town Board of Health? NO
2. If the parcel has previous approvals, list application ri umber(s):
3. Does this project require coverage under the New York State Pollutant Discharge EIbin ination System (SPDE ) PermiI
Program? —yes 1 L1Qo
4, Estimated project duration: Start Date= Zr*17 Fnd DWe: MR? 2612
5. Estimated total cost of project: A 1 .800
6. Total area of land disturbance for project; 8006-r-
Floor Area 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 Area Ratio [FAR]
Waterfront Residential WR 0.22
Commercial Moderate 1 Commercial CM 1 CI 0.3
Intensive
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) feet of ceiling height and covered
porches. Building square footage does not include: Open deck, docks and that portion of covered do&F, extending
over water and one storage shed of ons hundred twenty (120) square feet or less. Any additional sheds will be
included, (See"FLOOR AREA RATIU").
3, Commercial or industrial: the total area in square feet as measured frons 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 stmaures
on the project site.
Parcel Area 15 1 1, sq, ft.
Existing Floor Arca z (CS9. 3 sq, ft. see above definition
Proposed Ad ditional Floor AreR 2,2-4� 9 1 sq. ft.
Pro osed Total Floor Area 7-9 l k . zq sq.ft.
Total Allowable Floor Area '31419 ,11, Area x .Z'L see above table
Page 3
Arca V earlail ce [ZkAapproycd: Soplember2J2GI(i]
Comp]lance with,Zoning Ordinance
Requesting relief from SECTION': -:�-b q O 117� -1 I - b 1 t?
Need rel ieffram the requircrnent(s) listed be]owwhich can not be met by (lie pqject as proposed.
lCheek afl ihae oppi'.y] IL40 etbdck i ' BuffeJ'Zone Lot Width : 1 Other
The following questions reflect the criteria for granting this type of variance. Please complete them; use additional sheets if
needed.
I. Whether an undesirable change will be produced in tete character of the neighborhood or a detriment to
nearby property will be created by the granting of this area variance?
, Whether the benefit sought by the applicant can be achieved by some method, feasible for the applicant
to pursue, other than an area variance)
3, Whethcr the requested area variance is substantial?
4, Whether the proposed variance will have an adverse effect or impact on the physical or environmental
conditions in the neighborhood or district'?
5. Whether the alleged difficulty ,vas self-created?
Page 4
McCall Construction, LLC
1485 Courity Route 29 Quality First to Last
North geek lel' 12853
Phone; (513) 251-3619 Fax: (518) 251-5042
,area Variance Application Page 4
1, This house was built in 1934. The goal of the project is to make the original unfinished camp a
year round home. We would like to bring the electrical, plumbing, windows, doors, and
insulation up to today's standards. The Provenzano's also want the inte0or details to be true to the
period that the house vms built, When the project is complete it will be aTi example of a true Lake
George cabin.
. The Proven=o's house is a pre-existing nonconforming structure. The areas we are seeking
relief for is a proposed deck off the master bedroom over the existing first floor porch. A small
portion of this parch wi11 be in the 50 foot shoreline setback. We are also proposing a utility room
off the south side of the existing house which would be 4'3" into the sideline setback. The house
only has a very small crawl space which is not suitable for the utility needs of an updated home.
3. No, we are only asking for an additional 224 square feet of floor area for a larger entryway and a
utility room, The existing 1"floor will have minimal changes to the existing space. The kitchen
will bt- reconfigured and a half bath will be added. The stairs to the "J floor will be reset to meet
current building codes. The existing 2"" floor will be redesigned front 4 small bedrooms and 1
bath to 2 larger bedrooms each with a bath and a laundry room will be added. All with larger
windows to meet egress, light and ventilation requirements within the building code. The
existing 3'u floor bunkroom will be redesigned to a single bed and bath. A window dormer will
be added to meet egress, light and ventilation requimments.
4, Physically the property will basically be the same when complete. Environmentally the house
currently has an up-to-date septic system sized for a 4 bedroom house and when complete it will
have 1 less bedroom (3 total), The Provenzano Is ha,e a landscaped vegetation buffer(see photos)
along the shoreline. The total project is only increasing the nor-permeable area by 160 sq feet.
S. Richard bought the house in the 1980's in the condition it is in today. The house itself predates
the town of Queensbury zoning.
Area Variance [LSA approved; Supdcmber2l2016]
Section 179-14-030
Application materials and site plan drawing is to include sufficient information for the Board to review and provide a decision. The
applicant is to provide a site plan drawings)—a survey showing existing conditions,a proposed conditions map(see page 00 for
specific criteria) and include any other attachments that address A- D m applicable to the proposed project.
A. Gene-al S hown on Sheet 9
I Title,Name, Address of applicant& person res onsible for preparation of dra inZ (,fie
2 Deed 1-r r
3 north arrow, Tait IVtag 1D date prepared and scale fminimum: 1 inch�40 feet 1
4 Boundaries of the property I lotted to scale, zon ing bounds
5 Princi I structures,accessoa structum�s with exterior dimensions
6 Site improvements incl. outdoor storage areas, driveways, parking areas,etc.: existing &
proposed
7 Setbacks for all structures and improvements: existing 8 prgosed
9 Elevations and floor plans,ofali proposed and affected structures a 'k G
B. Water& Sewer Shown on Sheet 4
I Project sewage disposal facilities, design details, construction details, flow rates, and number of >1, reht<
bedrooms proposed h�.+eccJls�
2 Water supply [i.e. we]11 &septic on adjoining lots with separation distances to existing or VOL
proLyosed on-site water supply and septic
3 e aration distances for proposed sew a dis oral system to Orrell and water bodies
4 Existfng public or private water supply [well, lake, etc.]. Method of securing public or private
water, location,design and construction of water supply i nel uding daily water usage
5 Percolation test location and results
Parkin /Permeable Areas Sha ,n on Sheet #
I Number ofspaccs required for project including calculations and justification: existing c
—Proposed
2 No. of existing parking spaces, number tia bi�removed, number to maintain and type of surfacing
material P,-.g., gravel, paved]
3 Provision for pedestrian and handicap access and kin : exi8tina 8c proposed
4 Design details of in rens, egress, loading areas and cutting: existing proposed
5 Location and character of green areas [existing and proposed), modification to green area, buffer
zone to remain undisturbed
6 Lightiq& location and design of all existing and proposed outdoor lighting
D. Additional Site,Devel ment and Miscellaneous Show on Sheet #
I On-site& adjacent watercourses, streams, rivers lake and wetlands
2 Util ity I energy distributions stem s, electric, solar, tele hone : existin 4-proposed
3 Location, design and construction details of all existing and proposed site improvements
including. drains, culverts, retainin walls,fences,fire& emergency zQne5 and hydrants,etc.
4 Square footage of bldg. area proposed for office,manufacturing, retail sales or other commercial
activities: existing ra posd
5 S i gnage: Location size,type,design and setback: existing ro osed
6 Waiver Request: provide letter with application requesting any waivers: please reference
5 Gifu items
7 Commercial I Industrial Development requires submission of Landscaping, Storm ater
Mani emcnt, Grading& Light in g Plans
8 Identification of Federal, State,or County peimitFi required for the project togetlier with a record
of apelication for all necessa rin its
Page S
Pre-Submission Conference Form 1 Section L 79-9-040
,oma Variance [`LBAapprowedSGpLembcr21 2G 16]
X. Applicant Name:
2. Tax Map ID Location-
3. Zoning C'iassification UJ
` { f
4. Rcasnn for Review: C,�G�liill� �JT �{ �P �° ��t`{ ILI CJ rr�
5. Zoning Section #:
6. Pyre-Submission Meeting Notes: Provided 0utattading; Please provide b
Deed V1 S C C
General Information complete
Site Developmeot Data Complete
Setback requirements Complete
Additional Project Information Complete
FAR addressed 1
Compliance with Zoning Oi)dinance
Checklist items adda•esscd
Environmental Form completed
Signature Page completed
r Ct Ct( ` 1 )414
L7 trx -n-,hu C�t c�ck lY I t, 0,1
L C L. ,A P C1 C,4 i
. ,� ? f f L), -e
Staff representative:
Applicalot 1 A int: 4l Late:
I'age 6
t reZ aria'ICP_ [ZD A approved. September 2l 2016)
This page includes the 1.) Authorization to Act as Agent Form= 2.) 8ngineering Fee Disclosure, 3.) Authorization for Site Visits; 4.)
Other Permit Responsibilities; 5.)Official meeting Disclosure and 6.)Agreement to provide documentation required.
OWNER'S AGENT FOUM: Complete the following if the OWNER of the property is not the same as the applicant: -
Owner: S FfM "A"o
Designates: nug.,_wL Mc ,ate as Agent regarding the following=
Variance ve Site Plan Stnbdivisiwi
For Tax Map No,: 451- l-3 eedi�r nye: Bva $ Page_��j DateAP 1i 30 -
OWNER SI NATUR , DATE;
APPLICANT'S AUNT FORm. Complete the following if the APPLICANT is unable to attend the
meeting or wisha� to be represented by another party:
Owner
Designates_ I as Agent regarding the following:
'Variance Site Plan Subdivision
For Tax Map Ido.: Deed Reference: Book Page Date
OWNERSIGNATURE: DATE:
2.) ENGINEERING FEE DISCLOSURE: Applications may be referred to tate Town consulting engineer for review of septic
design, storm drainage, etc. as determined by the Zoning or Planning Department. Fees for engineering review services will be
charged directly to the applicant, Fees for engineering review will not exceed S 1,00D without notification to the applicant,
3.) AUT140fUZATION FOR SI'T'E VISIT'S: By signing this page and submitting the application materials attached herein, the
Owner, Applicant, and hWherltheir agent(s)hereby authorize the Zoning Board or Planning Board and Town Staffto enter the subject
properties for the purpose of reviewing the application submitted,
4OTHER PERMIT RESPONSIBILITIIG, :. Qtber permits may be required for construction or alteration activity subsequent to
approval by the Zoning Board or Planning Board, It is the applicant's tesponsibility to obtain any additional permits.
5.) OFFICIAL MEE'T'ING MINUTE DISGLOSU'RR- It is the practice of the Community Development Department to have a
designated stenographer tape record the proceedings of meetings resulting from application, and minutes transcribed froin those tapes
constitutes the official record of al I proceedings.
b. AGit>E~E SIT TO PROVE)) DOCUMENTATION RE UI 1J ; t, the midersigned, have thoroughly read and understand
the instructions for submission and agree to the submission requirements, i acknowledge no construction activities shall be
commenced prior to issuance of a valid permit. I certify that tbe application, plans and supporting materials are a true and complete
statement/description of the existing conditions and the work proposed, and that all work will be performed in accordance with the
appiroved plans and iu conformance with local zoning regulations. I acknowledge that prior to occupying the facilities proposed, I or
my agents, will obtain a certificate of occupancy as necessary. I also understand that II}ve may be required to provide an as-built
survey by a I icensed land surveyor of al i newly constructed facilities prior to issuance of a certificate of occupancy
1 have read and agree to the above_
Signature [Applicant] Print Marne [Applicant} Date signed
ign�'D Q, _ ,- udt McCelt& _7- t3-1�
atu e�r�gent] Print Name [Agent] Date signed
Page 7
' f 1•OUNT moi N.Ir.DF;so—rjuirS ramrU r�L,anK
wrn[L+_r'�rrr.yunua a1rr
� e,* �A, f flap of
11i S J�E�aadaora 111"Idred atlad Elghty-Eight
1m#wren 31 LRA A. �REERU, res fding at 9 Pine Circle East, Bonnington
Vermont 05201
f=rty of Ells rat pal-t, eu?d
wermant SMI RICHARD J. PROVENZANO. residing at 140 Hospital Avenue, Bennington,
port frf lite seooud part,
Iffiintawth that the party of tlaspdrat pare, In oonardemtiora(P---------------- ---------__
------------------------------One-----------------------_DQUar
lf"f+fttt )dDI a?! frf th'3 Urttletd $tpLea, and other good anis valuablR consideration
palm by thr,!;arty of eho s.B.Can l pai% floes hemby rernias, release and gfcalelaarrb
lzna o 1110 party 01 titc saaaud part, his heirs and osmates forever,all
MY RIGHT, T17LE An INTEPEST LH AND T6 ALL "THAI GERTAIN LOT OF LAND situated to the
Town of Queepsbury,,laerreri County, New York, and on what is known as Assarnbly Point,
on the ea$t share of Lake George, and designated as Lot Ne. Eight (3) on a map of the
First Sub-Diwlsion of property owned by the lake George Assembly at Assembly Point an
Lake George, barren county, N.Y.. made by Ernest " H. Meyer and filed in. the warren
County Clerk's Office December 7, 1914, bounded and described as follows: BEGINNING a
an Iron bort set In a concrete base for a corner in the southerly line of Lot. Hu.Nine
(9) at the northerly end Df the easterly line of an alley attd running thence adSterly
along the southerly linm of Lot No. Nina (9) for one hundred twenty-two and one tenth
feet (122.11 be the same more or less, to ars Iran holt set in a concrete base about
ee
six ft (G'1, more or Im, front the share of Lake George at high water mark, thence
still on the same course s I x feet (5'), be the same more or lass, to tie share of Lak
Gearga at high water mark; thence southerly along the share OF Lake urge et high
tater mark one hundred and one feet (1011), be the same more or less. to the north-
easterly coater of Lot No. sever' (7); thence westerly along the northerly line of Lot
90. Seven (7) for ono hundred thirty-four feet (134'), be the sar+e more or less, to
paint In the easterly lima of said alley, which point is the northwesterly earner of
Lot No. Seven (7); thence northerly at right aMJes to the northerly line of said Lot
be. Seven (7) and along the easterly line of said alley ninety-one end•-one-tenths fee
(91-1')- to aTr iron holt set In a concrete base for a corner; theme riortheriy still
along the easterly kine of said alley AtTrLy-nine and forty-fl Ya hundredths feet (39.
4S') to the point of beg irming.
"TOGETHER Kith all right, title and Interest of the pareses of the first part
in and to the roads, parkways and alleys as shown on the Map hereinbefore referred to
"BEING the same premises described Lrt a derld from Minnie C, Knight to Guy A.
Him and Edith 6. Ham (parties of the first hart hereill) dated September 29, 1947 and
recorded In the Warren County Clark's Office an October 2, 1947 in Rook 256 of 0eeds
at Page 245; and subject to the covenants and restrictions referred to therein.
Further swbject to an agreement between otyokwa, Inc., Ernestine C. Adamson, Guy A.
Ilam, Jr., and Edith G. Ham and others dated July 6, 1950 and recorded In the warren
CDunty Clerk's Office on July N, 1950 In Book 269 of Deeds at Page 412, relating to
covenants and restrIcklons.
Being -the same premises conveyed by Guy A. Hare and Edith G. Ham, his wife, to
R1 Chard 0. Proverizallo and ;Jutta A. FreHlian, 1115 Alfa, by deed daCi�d flu wermber 21, i9B3
and recorded in the Warren County Clerk's Office on November 30, 1S&3 In liber 658 of
Deeds at Page 97.
Fes~
GAIL 71
TATE
Gil.' FE TAX
C, UMTY
i
"nUUR*r TWA,tAa amyl all ma ¢gtat6 a7rd. rdelaLg of tlta party
of tho first part M and to sated preuxises,
��pF p T2p1 tJ}a pramim hilrUpt, �Fflatad :veto Etre early of tdre
Aecon d chart, his haisre rd asL}ipja forever,
Jn ?iiEl�Grnar 3Itlirrrpf, tlae prlrt y of th0 first dram'laa. 5 her
F+ hrrurd ajuf.aaarr2 the rlabr find Year j1p.9G abotla roraLLmr„
ibi 011 Prumice of
rx tet. d?w,u,&r �
'fes" -j
kala. Lit 2CKX,%Ipd
l� thi9 '�'� clay or
puntls of !e NiNdraeecon, Hrmdrecd aj4d Eighty Eight
beforo rues, the :id xe,'fdia,, +Grgvr, dd alxpearerl
JILUA A. FREON
f.0 rue frersorrOily ILJF0701b and h:rrerear+,da nto der be She sarue lrerawa dcxoribod fn are6
rulao exsurtted Oie within Insimrrr.ant, yrrld. SIta aekrrateled&d
to rrae L11121. Shp execraterd dire aurr�c.
Not-ary Public
E-lair of Virtu lJor]t
Rya L72fs day of i
ir�rslut�� {ti �a Afuetem Xrarjrlrerl and
bcfnrc rarer the subaci-Wo'r faQrsolr01y appeared
to uaa frarm raoridr}fortown,and knorpm.to up do ba tha:aura d,?rar,re, deavrdfietd In aFed
re:Tto 4%wwc4ed ilia within hutrterr mi, and lie ackrrnrcledfetd
IV rma thrit he axecreted IhL sarue.
` �/ •4ryJ LM W � {F
W l yl F
1
A6 fe u' - b a-I
Iz
ry � b o
i y.. � I �
+ .. z
� cc � cG�1•
ri
i
l
169 H�j+rAand Road
Queensbury, MY 12804
Hutchins Engineering Phone; (518) 745-0307
Fax; (518) 745-0308
July 12, 2017
Mr, Craig Brown
Town of Queensbury Buildings and Codes
742 Bay Road
Queensbury, NY 12804
Reference, 6 Neighbors Way; Septic System Certification
Parcel ID A 226.15-1-30
Richard Provenzano
Dear Mr, Brown,
I have reviewed available documentation describing the installation of the septic system at the
referericed property, This documentation, includes the fol lowing-
• A drawing entitled "Provanzano Residence — Septic Design" prepared by Morse
Engineering, P-C-, dated July 21, 1992, with record drawing markups dated August 6,
1992-
Queensbury building permit file ##92A26 which includes referenced plan, permit #9 -42
and Septic Disposal System Inspection report dated July, 24, 1992, The inspection report
indicates the system was installed in accordance with the approved plans.
Based upon the documentation referenced, the system consists of a 1,250 gallon septic tank and
one 20' x 54' pipe-in-stone aibsorption bed, The system was installed by Friedman Excavating in
July of 1992.
There is no water supply well on site (lake waiter supply) and documentation indicates horizontal
setbacks to the shoreline and neighboring wells are maintained to current standards (100'
absorption field to lake and weli-1 50' tanks to lake and wail). The absorption bed as documented
have appropriate absorptive area for a four bedroom house at the current standard.
Based upon my reviaw of the above documentation, it is my opinion that the existing septic system
was sized and installed installed in a manner compliant with the current Town standard for septic
systems (Chapter 136).
1 trust this information is sufficient for your immediate needs, however, pie ase contact me if you
wish to discuss.
Best Regards,
G. Thomas Hutchins, 13,17,
Cc.
Doug McCall, Contractor
G.Thomas Hutchins,P-E. thutchins hutchinsenginearino.cam
MORSE ENC,
TRANSMITTAL
FaX 792 - 5049
rllAk� * 89 LOWER DIX AVENUE
!! ,- -QUEENSBUR F#.Y, : 5
Town of Qu&ewsbury
(ha�)d Del ivered) DATE. august 6, 19 2
JOS NO. r—
ATI-EENTION: Dave flatln RE. prop+enzano Residence
Y'rE ARE FORWAR DII G M UNDER SEPARATE CODER KK HEREWITH
:c7 DFIAWINCS 0 SPECIFICATIONS ❑ SHOP DRAWINGS ❑ CATALOG DATA
I'1 SAMPI-ES Cl ADDENDUM(S) Cl SUE3MITTALS 13 OCHER
I
14-it FOLLOWING: Two sets of prints for Provenz;,no Residence septic des ign , .'s.igried.-and
,,ealed , for your records .
Z am sending o-ne sit to Dr. Provenzano for his records.
r
f'
HESE ARE: FOR Y 7UA Fli. ! } EXCEPTIONS TAKEN R J r.'ED AQ NC TED
'RK5'
)r . Provenzarno VERY TRULY YOURS,
y ,ate
Fq / / T+ 0 � 2 M
CD 20C �¥ 21 � 4
o
, 132
�* = 7 7 � fo 0
§ o a w a � 0 \
2CL
ID
0M ¥ k ƒ
§ � CD C
w 7 �7 2� � kJ � e �
tn
, ° u < 7
§ a °
) E 7 Dy nq m2 e \ :
2 ° ® ` ® _
� k
§ M § ^ ± r+
7 / \ M /
; ® K e § f
m CL
kD §
. - a )
h \ 7 \
n = fD \
mm -0 Ln §
rp
INTERIM P[RKIT TO OPERATE A WASTEWATER TREATMENT SYSTEM
owner' s Name (permittee) _ Richard J. Provenzano
Street dress: !l Catamount La
City: Bennington State: VT Zip: 05201-1708
Facility Address-Town of Queensbury.:
Assembly point -
Tax rap Number: Section _ 9 Block I Lot
28
This permit will allow you t0 operate a wastewater treatment s m at
the above address and authorizes you t0 discharge from this facility into the
groundwater of New York Staff in accordance vith the Conditions and requArernents
of this permit. .
THIS PERMIT EXPIRES THREE YEARS FROM THIS TE: M 0�fa-3�
91
� � z
y Year
SIGNED: « -
DAVID H TIN , I EQFOR
BUILDING AND CODE ENFORCEMENT DEPARTMENT
Short Environmental Assessment Form
Parr I - Projea information
Instructions for Completin�
Part 1 - Project II&rmation. The npplicant or prDjert sponsor is responsible for the completion of Part 1. responses
become part of the application for approval or funding,are subject to public review,and may be subject to further verification.
Complete Part I based on information currently available. Ifadditional research or investigation would be needed to fully
respond to any [tem, please answer as thoroughly as passible based on current information_
Complete a]I items in Part I_ You may also provide any additional information which you believe will be needed by or useful
to the lead agency;attach additional pages as necessary to supplement any item-
Fa rt
tem_Part 1 -Project and Sponsor Information
Name of Action or Project;
Q V V N Z FI0 0 No%JorrIO V3
Project Location(dcseribe,and attach a location map);
Brief Description of Proposed Action_
r.0cvwriz � ���i��� eA5aA"fL�
_TN 5dLOrr M/ H4097M PbAlM
Name of Applicant or Sponsor: Telephone; �, �_ q
1 .7 6 CC � IM J( Tro+,s 'lE7-r !T JhT-
Address' _
Cityipo= State; Zip Code:
o z-�it C ive a .\'- 1 1 a Pr
]_ Does the proposed action only involve the legislative adoption of plan, local law,ordinance, NO YES
administrative rule,or regulation"
If Yes,attach a narrative description of the intent of the proposed action and the envi ronmen tal resources that
may be affected in the municipality and proceed to Part 2_ If no,continue to question 2.
2. Does the proposed action require a permit,approval or funding from any other governmental Agency? NO YES
If Yes, list agency(s)name and permit orapproval; E� ❑
3,a.Total acreage of the site of the proposed action? y r 1 % 5 IF ,ams
b. Total acreage to be physically disturbed? $ 6 gr aWW
c_Total acreage(project site and any contiguous properties)owned
or controlled by the applicant or project sponsor+? I . $ axes
4. Chcok all land uses that occur on,adjoining and near the proposed action.
❑Urban ❑Rural(non-agriculture) ❑Industrial []Commercial ❑ResidentiELI (suburban)
❑sorest ❑Agriculture ❑Aquatic [ other(specify): VJ —
❑Parkland
Page I of 3
5. is the proposed action, NO Y Es N/A
a. A permitted use under the zoning regulations? ❑ ❑
b. Consistent with the adopted comprehensive plati? ❑ 12r ❑
6. [s the proposed action consistent with the predominant ch aracter of the existing built or natural No YES
landscape? ❑ F1
7. [s the site of the proposed action located in,or does it adjoin,a state listed Critical Environmental Area? NQ YLeS
if Yes,identify: 2 ❑
8. a.Will tht proposed action result lit a substantial increase in traffic above present levels? NO YES
❑
b. Are pubJic transportation smioo(s) available at or near the site of the proposed action? n ❑
c. Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action? l�1 ❑
9. Does the proposed action meet or exceed the state energy code requirements? NO YF._4
If the proposed action will exceed requirements,describe design features and technologies:
❑ ❑
10, Will the proposed action connect to an existing public/private water supply? NO Yrs
If No,describe method for providing potable water: ❑
11. Will the proposed action connect to existing wastewater utilitieV NO YES
If No,describe method for providing wastewater treatment: z ❑
12, a_Does the site contain a structure that is listed on either the State or National register of Historic NO VE
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 NO YES
wetlands 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 waterbody? �"� ❑
If Yes, identify the wetland or waterbody and extent of alterations in square feet or acres:
14. Identify the typical habitat types that occur on,or are likely to be found on the proj eel site. Check all that apply:
[ Shoreline ❑Forest ❑Agricult uraUgrasslands 0 Early m id-successional
❑ Wetland ❑Urban ❑Suburban
IS. Does the site ofthe proposed action contain nny species of animal,or associated habitats, listed NO 'SES
by the State or Federal government as threatened or endangered? Iii' ❑
]b. Is the project site located in the 100 year flood plain? NO YES
17. Will the proposed action create storm water discharge,either from point or non-point sources? NO VFS
If Yes, ET EJa, ill storm water discharges flow to adjacent properties`,' [71 NO ❑Y C
b.Will storm water discharges be directed to established conveyance systemstm
off and storm drains)?
If Yes,briefly describe; ❑YES
Page 2 of 3
18, Does the proposed action include construction-or other activities that result in the impoundment of YES
water or other liquids(t.g_reten ion pond,waste lagoon,dam)?
If Yes,explain purpose and size: ❑
19.Has the site of the propscd action or an adjoining property been the location of an active or closed NO VES
solid waste management facility?
If Yu,describe, � J�
20, Has the site of the proposed action or an adjoining property been the subject of rernediat[on(ongoing or NO YES
completed) for hat dous waste"
If Yes,describe: ❑
I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY
KNOWLEDGE
Applicant/sponsor name. � 4w] SAIL M C.(A l I Date: 7 - 1 - 1'7
Signature: q6 R
PRINT FFtM Page 3 of 3
• .5�x�. {, ''4 k :1 try
IL
}t k+�.4s.Y] r � �1,�, �: 'y` li` a' i �,� J2i■r r_
314
.'t
5 _
.Fa i ll
Al
ILI
t
yyF. t f l
irk.
dk
. l� � �I�1�'IIL,6 ri—.'T!.".',.�� � �'~r ,��,••y � •, s .r i - .� I�f'+jj �}.�.•}.�
°.
' �, 1 'r•f - 1 ta, I'7
all
'rA2
# + Y
I
';sL •h
„I r} ._a- - - --
17
•