Site Plan Application 1pl �o
'TOWN OF y.. y`i „
URY
Site � w
iq,#,..
Reviewrs
I. Required Pre-submission awith staff, to detenniner ,,Vo,-tq p. � lr� � � �u
g ,rit r to deadline nl®�L,. Call (5 18) 761-8265 or,(5111) 76
. Submittal of complete application,, 1. original and 14 copies of'the application package by monthly deadline.
. Determination of application completeness. All necessary ire onnnatiern must be pro vii ed and appmptiate
fees)paid for consideration.for placement on an agenda for that month.
4. Incomplete aggileations will not be,,,,,E2ng0dtLe& fairlaee gent on anjenda gntil all issi
lnfo,rma " e :c snack t , »,
5. Submittalto Warren County Planning', if applicable.
i
. Planning Board meeting, generally the third & fourth Tuesday of each. month. You ill. be advised in
writing as to which meeting to attend..
7.. Following the meetin,g You will be provided with a c py of the resolution stating the Board's decision on
our application. If your application was approved, the next likely step is a Building Permit. Final
dra fangs rnnunst be provided fuer the next phase ofreview. If your application was ,dernier, your project cannot
proceed as submitted.
DOCUMENTATION _ E � hay l troni
Please submit I 2E pn_A 14 pan es of-tine completed,application package to include:
0, Co,MgLeteg ADDHeatl2apages 2-9, signed & dated
XER&PIMISsion Mgggft lel signed by stiff
' ppy of DgLed
Qecklist, F Plant Plan
rrnrna nt 1 ssm t Form m for any atom-residential project
Fee 100 —, 10,000 sq. .), 50 (10;,01 1 — 30,000 sq. .), $500 0', 01 -100,000 sq, .) 1, �
10 ,011 + s . .)
Staff& Contact Information
Craig Brown,, Zoning,,Administrator en b A
ObanOtt
Laura Moore,, dUse Planner 1 re pCrsh .;rett
unrnrn , Office Specialist--Planning s:ungvs&ul2usbu Imet (518) 761-822
V�isir our websiw at A , sur° .nf r further information and forms
Site PIS Review appVk& on—RevisedOctober 20,16,
Town f ns wy Planning Offic -742 Remy Mtn,Qaeensbury, NY 12804
General Infomiation
Tax Parcel TD Number. 290,14-1,-20
Zoning District; MDR
Lot size:: 104108A sq ft 2.93 acres
Detailed Description cription f P'tOj ect [includes cu ne nt&p posed use]:
Rebuild bome destroyed by fire with proposed 192 sq f1 additional fiving,space add d to fbotprint
Location, of pproject:
3 Marten Rei,Queensbury
Applicant Name: Mike Lewis Address. 52 Fox-Run.
Home Phone 518-494-726Cell:
W rk Phoma 518-494-7265 Fax
ik l wi hi 1npeakslo la nes.co
Home Phone Cell:
-mail -. -
ner"s Nameddr�,ss 266 'fiddle rd',
��� Swift
Home,Pinott
518-685-5093 _ Cell 1--860-30 5-8670
Work Phone 518-685-5093 Tax
E-mail
i
de�rekswftgmafl.com
Site Plan Review appiicafloza-� Revised October 2016
2
Town of une burrylan,nh g Office-742 Bay Road.,Queensbury,NY 12804
Site t Data
Area Type Existing si—Jt. Proposed Total sq. ft.
Ad it p s „ft,
A. Building.fbotpnint 576 192 768
B. Detached Garage
..
C. Accessory our s;
D. Paved,gravel or other hard surfaced area
E Porches/Tec 0 92
F. other
G. 'Total Non-Permeable [,add -P";j
H. Parcel ,area [41 ,560 sq. & /acre] 104108A s3 ft 0 104108.4 sad ft
2.93m s- 2.93 rays
I er lrmt,a a of impermeable Area,o Site [1— lli)
t au ire uir ment
Area Required_ ExistingProlposed,
Tont [ ]
Shoreline 75 50,+/- 67 44-for new
50+l fair fou ndatio u
,Side Yard [1] est 15 8� . 80.9,
Side "hard [ ] East 13 67.9 7D
Rear Yard
Rear Yard [2]
Travel Corridor
Height [maxj
PermeabilityNo. of parlang,s�paces
3
Site Plan Review application n—Revised October 201
'own of Q ueeunsbu Planning m-742 BayRo4 Queensbury,NY 12804
,Additional Protect Information
1. Will the proposal require a Septic Variance ftom the Town Board offlealth?' No
2. If the parcel has previous approvals,list application number(s):
3. Dees this project require coverage under,the Ne:w York State Pollutant Discharge Elimination System
(SPDIE,S)Permit Program ? No
4. Estimated project duration: Start Date Nov 2017 End haute May 2018
5. Estimated total cost of project: 0AN,
6, Total area of land disturbance for project:
Floor Area Ratio Worms beet
FLOOR AREA RATIO (FAR) — The relationship of building size to lot size, derivfd by dividing the total
building floor area, by the lot size in square feet, yielding a percentage,
Zon�ing Disiu�ct mm, l cul Floor Area Ratio [FAR]
Waterfront Residential WR 0.,22
Commercial Moderate/Intensive CM/ I— 03
A. The cornbined area, of all, square footage, as, measure frornexterior 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 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 RATIO").
B. Commercial or industrial: the total are, in square feet as, measured from the exterior of the outside walls of a
building or structure,,, and when applicable, the: sum total of allfloor areas of, the principal and accessory
buildings or structures on the project site.
B. Existing Floor area S ., ft.. [see above definihorJ__
C'. Area,
D. Prop Bed Total Floor Area sffi
E. Total Allowable Floor Area ea x [sop- nhnye table]
*If D is larger than E. a variance or revisions to your plan may be needed. Consult withStaff.
4
Site Plan Review application-Revised October 2016
Town of Queensbury,Planning Office-742 Bay Road,Queensbury,NY 12804
179-9-080Regui�rements for Site Flan Avoroval.
the Planning Board shall not approve a Site Plan unless it first detennines that such site plan mel the
following Standards. Please prepare responses to each of the following topics:
STANDARDS
A. fhu proposcd—p—iroject fhr&—:rs or—1s consistent with the policies Of the'Town"s Cbrnprefi�nsivc Plan,
1 .
The proposed project complies with all other requirements ofthis Chapter.,includin the,site plan review standards as set forth fti P
.orting district in which it is proposed to be Located(Article 3,and
F of this section,the dimensional,bulk and densfty regil lations of the? 9 aragraph
1),the applicable requirements:ofall,other Articles that aippfy,
C The
The site Fla'n—encourag—es pedestfian acd if practicable,to and fi-om the site with pedestrian paths or sidewalks connected
(),C
to adjacent areas.
—57site plan,must conform to Chapter 1316 Sewage and Sewage Y1 sposall,�Cliapter 147 Sto�m—waterManogement�111.ocal Law,an d—offiel
applicable local laws,
E, use shall be in harmony,with the.general purpose orinten t OF this Chapter,specifilically taking i�ntO accolmt the location,
character and size of thC proposed'usic and the description and Purpose of the district in whieh such use is proposed,the nature and intensity
of 010 activities to be involved in or conducted in connection with the proposed use and the nature and rate of any cr
supporting p�ublic services and fal whiCllrill NIOW the aP�Proval lafthe proposed use- a in ease in the burden on
The,,establishment,,maintenance and Opell of the prop used use will not create public hazards,ftom traffic,traffic congestion or the
parking of vehicles an&or equipment or be otherwise dictrimejual to the health.safety or general wM fare of persons residing or working in
the neighborhood or to the general welfare of the town. Traffic ace ss and circulation,road intersections,road and driveway widths and
traffic,controla will!be adequate,,,
ff
C C Ot
Off-street arking and l
p9oading faculties will be appropriate y located and ranged; ffito
and sucie;t meet�trafflc antkipaicdto �eneraUcd
—b�
by the new use. The establishim-nt of vehicle I inlubetween parking areas of adjacent properties are provided where,Feasible, Th is furthers
the Town's goal 0(reducing curb cuts and ri ng congesdion, A twenty-foot wide,connection is requi red, If adjacent properties are either
undevclbped Or Previously developed%vi thiout having ni provision for future liOkaac� ffieAa future corintction must be identified mid
provided fur in die site plan under review for such future linkage when the time arises- Ilie Planning Board may require proof that the
applicant has imdc contact with adjacent property owners,for purposes of roordinating linkages witbadjacent pay req
fl.. The project shall Flot have an undue advarse impact upon the natural,seen io,aesthetic,ecological,wildlife,historic,recreational or upcn—
space resources of the town or the Adirorildack.Park or upon the,adequate Provision of SUPPorti Nfacilities and services made:neecssary by
the project,,taking into account the commercial,industrial,residential,recreational or other benefits that might be derived from the project.
In making the determination tic mWunder„the Planning Board shal I consider those eters pertinent to,IM Project cointain.led in the,
development considerations set forth herein under§ 179-9-080 of this Chapter,and in.so doing,the Planning
evaluation of the project in relation to,the development objectives,and Senierail ,Board shall make:a net over�all
I guidelines set in§ 179-91-080 of this Miele,
'The pro vlsion—for and arriog�---'
anent of Pedestrian traffic access and circulation,ZW141Y 111uc�res,co��t—rolof
straffic and overrovidall peeddestrincouan conveniee pence
shall bleuse.,safe and,adequmve
atc for pedestrian oment. Pedestrian Connectibris between adjacent
�es s.hall be pto eragrian
J. S tormwater,drain
's ase of post development drainage flows as compared to pre-development drainage,flows-..
lcl'it'c'
gu f
site
sha"'recharf gr
Drainage of the s' the extent practical. Surface avers flowing off-site shall not degrade any strearns or
a n ce )n, '
adversely aff t drainage( adjacent 0
adversely affect blioroads, Fnilitiess�halibeincOn�formancewithithedraine�ges�timdatds t'Chapter
1,47 of the'Town Cod and
the
Town Subdivision Regulations where applicable.
Th wii ,p ly— _
cr� p d,Sew g,d,
K. a an Isp 0 1 1 a d eiq u a an d wi,111 me—ot all a pp 1—1 —
Department of Health raguladons and Chapter 1�36 the Town Code., cable and current requirements pct forth by
The adequacy,type and arrangernent:of trees,shrubs and ether suitable tirigi,landscaping and screening cHvWY provid
ca
iible plan'tin,91 shall effe
visual an(Vor noise buffer between the,applicants and adjoining lands,including die maximum retention lufcxiging vegetation and
maintenance,including rient of dead or deceased.plants.
M. Fire lanes,emergency zones and fire,hydrants wj;l I be adequate and meet the:—need;and requirements of emergency service provideT.S.
structures,r—oadways,and landscaping in areas"susceptible to pionding,flooding and/or erosion will Minimlie Or avioid such
impacts to(he maxiinum extent practicable,
LT
The site plan con:onrils,to gluede ign stan]—ards,land—scapil`e design of str ng:standards and pertbraiance standards of this chapter.
Site Plaut Review application—Revised October 201.6 5
Town of Queenisbury Planiling Office442 Ray R04 Queeni NY 12804
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§ 179-9-050 ll heel for Site Plan Review.
Application mat is and site plan shall, include sufficient information for the Board to review and provide a
decision. The applicant is to provide a site plan drawing and all attachments that address, item's A-�V. The
applicant ma,y request a waiver frimA-Vand is to provide reasons for waiveis) requested. Please label
information,to be Submitted.
RE REMIENTS
e t#
Sl:eet#
A vicinity'ina "i
p drawm at die scale that shows the relationship of the proposal to exigfing cotninUnity Faci I Wes which affect
or serve it,such as roads,shopping arcas,schoo[ A
,RE 'N"'�'
draw'J"p 7 n at 0
L'ity
R -7
FE
'Q
V-1c
, s ffi a,ro
r secure it.SUL ad 9.etc, I'lle Map shal I also show all properties,identify owners,
u ce
bdivisions,streets ad within 500 feet of the property. Such a sketch may besuperimposed ovil a United States
O su to
IS' V arum of the area.
'a c
e�ll b�
leo o 'ca "ur
14Y
.�e si�rc Ep L11an s�a��bd�,rawn at a kale of fon ty feet to the inch(1 40 feet)or sudh other scale as the Ptannit4kg Board niay
doom appropriate,on s9andard 24"x 36"sheets,with continuation on 8 V2"x I I tt sheet's as riccessaty tor Wriften A
:information. "I'lie inffirTnation listed belo,w shall be shoam on the S1
ikjj��nflnuation shee�q,
Name of the project,boundaries,slate,north anrow,and scalt Axl G p1m
A
,A
D, Nanwe and address,of the owner of record,developer,and sea]of the ungincer,arcliftect or landscapic architect, if the
A
applic ant is not the r,=rd owner,a lettarof authorization shall equd ftomhe o
all be riretwner.
F_ ThMall existing and proposed structures within the property,including a]I dirni.ensions ofheight andand,411 an ic tiott!Leo�re ad ti ntrances. di ons and aftcra
T�e location Rall nese and proposed public and private ways,off-street parking areas,drfv�Z�,—outdooi'Tto—riage ar��—s
ences, Location,type and screening&I W is for a]I waste disposal A
sidewalks,ramps,curbs,paths,landscaping,wallls�and f
noiners s a so 0 0
,d Cnd scenl�''t"
crtie M
n In
in
C(s to i�[�,�n
gl
�n
c l"Ett i t intensity
"Z and b'lb'type
l minat in he ih uni
lu 10"and me 0 1 1 n t to
[out 0 eig 1,'im, at'rils
M�n as n of I prop",
H. he h h anal design d si�nF
The location Ofall present and proposed urilitys
I- Sewage Or SEpliC SyStern; East si&
2. water supply systern, of haeme,
2- West
3,, Telephotic,cable and ejectrjca�[s sterns;and side:of home
1 3 Sheet A,
4, Storm drainage system including existing and proposed drain lines,�culverts,catch basins',headwal Is.end Is, 4 sheetA
hydrants,manholes and drainage swales.
he 14—
ss've ran
ex"'
r app
rkd Tde el
po"'utio"Osu
"an'"o preve soil both during and after construc.t—ion,'excessive runoff
and fl IiRU 0'O�cr p pertles.a'
tj , ,
't7
tJ' v opme
ha
a'c P I's
ae excld g a cu Wr' tiOn PreVentiOn Plan(SWPPP),for all land development
p y it C results i land discudbance�ofone acre oTroore., ASWPPPsI)all
h th mr9 orth,
It h b Jr
rmit and Chapter 147 of the Town of Quicensbur
be at wr i Orl y
the di eticin
her a SWPPP or an ero,&[on and control plan shall 7ble
required for a plan review project land disturbance of less than one wre,
o ru0el air suaetu a ". --------
-r
eno
ngra�' a,'we-
'r 10 Jhc neare
refer
"area w p rt shall11
"rep0dplfiin,�th
O"ed"0' cur
e, s 'Contour interval as the Pla inin Board
allow. A ovation sla
100, flb detic Bench Mark. If any :0 �ion olf the parcel el
is widiin the
se(t5't' "t i'l 50,Fact 0 rd"P tions given- Areas shall be,indicated within
the prop d h
'le prop' b. filling is required,showing the approxinute
volume in cu �c ymrds,.
aT—
andscape plan
outcrops, standserrurvene delign of the propose use such as,rock
changes to thesezes water,sources and all proposed
watercourses,,aqu ads takes, and
and
u�ru areae..
M. Land 1Ise District VM and identified on the site plan,as,vvell
as any )Vcr1ay Districts that RPOY to die:property,
Site Plan Review application ReMsed,Olutober 2016 6
To of Queensbury Planning Office-742 Bay Road,Queensbury,NY 12804
REQUIREMENTS (CONTINUED) Sh e#
Mi Traffic flow patterns with in the ske.,entrances and,ex ks,loading,and unloading areas,as;well as curer cuts ort the site and
within 100 feet orthe site. 17be Planning Board may,at its discretion,require a detailed traffic study for large developments or
�for those in heavy traffic areas,which shall include: )PEW,iii
t, "Me projected number of motor vehicle trips to enter or leave:the site,estimated(br weekly and
annual peak hour traffic levels;
2. i projected trafflic flow pattern including vabicular movements at all major intersectilons likely
to be aMcted by the proposed use of the site;
3. The impact of Us traffic onlevels of smic!e on abutting public streets and at affected
Lintersections. Existing and proposed,weekly and annual peak hour traffic levels and road capacity
levels shall also be given.
For new construction or alterations to tinny structure,a table containing,The follovii information shall be included,
L Estimated area of structure to be used for particular purposes;such as retain operation,office,
Storage,etc.,, lo
2:. Estimated maximurn number of eMployeCS;
I Maximum searing capacity,where applicable;and.
4. Number of parking spaces existing,and required for the intended ui
1. Floor Plans,
2. Elevations at a scalcof one-quarter inch equals one loot(1/"4° =I foot)for all exterior facades mfThe proposed,striticture(s) B
and/or alterations to or expansions of existing facades,showling design featittrus,and indicating the,type and color of materialij,
to be used,
Soil logs,water suppl�y well and pericolatioll,test Q. re torm ru mitigate pToject impacts- sults,and s water noff calculations as needed determine and
C"
Plans for disposal of construction and demo fition waste,either on-,site air al an approved disposal facility.
Mans
fever
M Z
11 IV ILI
w removal, including location(s)of on-site snow storage. E 4
T. An Environmental Assessment Form("SAF")as required by the Si I RA regulations, with Part I co repleted by the Applicant
shall be submitted as part of the applicatioll, ll"the proposed project requires a special use permit and an EAF has,been
aubmitted in Wniunction with a,Vecial use permit app]iention,a duplicate E is,not rzqnuired for the site pilan applj'"Iion.
U. if an application is for a parcel Or parcels on which more than one use is Proposed,the applicant may submit a�slngle
application (or all such uses,provided,the proposed uses are flecurately'delineatcd on a site plan drawn,purswnt to the
requireirtnts set forth above. The Planning 13oftird may grant the application with ri to some proposed uses and not
others. For purpio,scs of revicwin �an application(and for SE MINA corapli� nce)all Proposed Uses on a sngleiparcel or oil
Contiguous parcelshat'.] 9 A)k
E be consirdered,iogetheer.
V. A brief narrative statement on FWthe�projecfprrfflopmqeW liar revicWTUrthers or is consistent with the vision,goals and poilicies
in die Town's Comprehensive Plan., 3FI5_—I
LIILI��R -S
Site Plan Review Whication.—Revised October 2016 7
Town of Queensbury Planning,Offlice-742 Ray Road,QueLmsbury,'NY 12804
Town of Queensbury Site Plan "re-Submission Conference Form Section 179-9-040
a
. Zoning Classification
4. Reason for Review
.5. ZonIng Section,9: Tcy
6. Pre-Submission Meeting Dotes: ProvidedOutstanding; Please pride b
Deed
General Information complete
Site Development Data oma l c - N
Setback.Requit-ements Complete �
Additional Project Infommmtion Complete L f-
', addressed
.Requirements for Site Plan-Standards
Checklist items addr d. k
Environmental Form completed
Simature Page completed �
irk (CI tb
ef eld re V,
ro
,.
L . `' 'q w
coa
Stuff Representative: " wrk
licant/ gent,: Date:
8
Site.Plan Review application—Revised October 2016
",own of Queensbury Planning Office-742 Bay Road,Queensbury,NY 12804
Signature Page
This page includes the I. Authorization to Act as Agi nt Forin: 2.) Engineering FeeDisclosu're; 3.) Authorization for She Visits;4.)
Other Permit Responsibilities; 5.)Oifficial Meeting Disclosure and 6.)AgTeernent to provide documentation required,
OWNER IS AGENTIFRM:
ComPlete;the following,ifthe O "NUR of the property is runt thesame as,the applicant
Owner:
Desigriates:
,As agent regardi g-. Variance Site Plan Subdivision
r aro'
For Tax Map Section Block Lot
Deed Refe Book Page Date
OWNER SIGNATUJ�RE: DATE,
APPLICAN'r's AGENT FORM,
Complete the following if the APPLI CANT is unable to attend the meetingor wishes to be represented,by another,party.
Owner-,
Designates:
As agent regarding: Variance Site Plan Subdivision
For Tax Map No. Section Block Lot
Deed Reference:
Book PageDate
DATE:
L) IGINELAING FEE IDI SC1,01,91 in sr,'. Applications may,be referred to the Town consulting engineer for review of septic design,, strum,
drainage.,etc. as determined,by,the Zoning or Planning Department. FecisfDr engineering review services will be charged directly to the applicant,
Fees for engineering revues Will net excited S,1,0010 withoutnotification to,the applicant,
3,11 AUTHP It T'ION A,SITE VISIT$. By si niog,this page;
L ZA Fj) g and submitting the application materials attached herein,the Owner.,Applicant,
and hisAteriftir agem(s) hereby authorize the Zoning Board or Planning Board and"i Staff to enter the subject Properties for the purpose of
reviewing the application subrnittedl.,
4.) OTIIERPERMIT-AESPONSIBI'LITIE S: Other permits maybe required for conitruclilion oralteration activity subsequent to approval by the
Zoning Board or Planning Board. It is the applicant's responsibility to obtain any additional permits,
§_L_QFF1C1A,L, Affi TING MINUTES;AIMMURE- It is the piractice of the CommunityMvelopment Department to have, a designated
stenographer tape record the proceedings of meetings resulting from application, and minutes transcribed frorn those tapes cis The official
recard of all proceedings.
6.), ACQR&FMENT T0rg0yLpE I,the undersigned, have thoroughly read,and understand the instructions
_J�OCUME N REQUIRE
for submission and agree to the submission requirements,,I acknowledge no construction activities shall bit commenced prior to issuance of a valid
permft, 1,ceri that the application,plans and supporting Materials are a true add complete statement/description of the existing conditions and the
work proposed, and that alt work will be performed in.accordance with the approved plams and in conformance with local Zoning,regulati I
acknowledge that prior to occupying the facilities prqposed,I or my agents,will obtain a certificate of occupancy a-,necem ary. I also undcrstwid,that
Uwe may be required to provide an as-built survey by a licensed,Land surveyor of alt newly constructed facilities prior to issuance of certificiate of
occupancy
I have read and agreet�thhe above.
'du"nu a "c
v I r;
2
Ig' p t] Print,Name [Applicant] Date-signe�d
—--— —-----------
Aippature [Aggeent] Print Name [Agent] Date signed
,9
Site Plan Review application—Revised October 201.6
TOwn OfQueensbury PlanningOfflice-742 Bay Road,Queensbury,NY 12804
Short Environmental Assessment Form
Part I -Projea Informadon
Instructions for Completing
'Part I -Project Information. The applicant or projec,t spol Is resPoffliblefor the complieltion,of Part 1. Responses
become,part of the application for approval or funding,are subject to,public review, and may be subject to flu-ther verification,
Complete Part I based on inforniation currently available, If additional research or investigation would be needed to fully,
respond to any item,please answer as,thor-oughly as possible based on current inferrnation.
COMPlete:all items in Part L You may also pTovide any additional inf6rMation which you believe will be needed by or usefu I
to the lead agency,attach additionalpages as necessary to supplement any item.
Part I-Project and Sponsor Information
Del SwA project Mike Levillis
Del
Mft project
Name of Action or project:.
1
Derek pSwift home,
1-ocation mapj`--
Project Location(,describe,and,attach a
43 Martell Rd
Brief Description of Proposed Action: . .......
Rebuild 57,6 sq ft folotprint with,add[fionall 192 alt ft. Audrey Swift artd her huisbandl are the occup ruts of the holm!e and are�85 and1901 year of
age respectWely.The addRional spaloe will imalfe[he first 11,olor area a much more comfoftble space to reside as they raril dilmb stairs.
Name ofApplicant or Sonsor,
p Telephone: 518494-7�265
Mike Lewis
E-Mail, mikePewls@highpeaksloghomes,com
52 Fox Run
city/po:
own S'tat,e dip Code:
Chestert
[NSem,'York 128117
1. Does the,proposed action only involve the legiWI—ativeadol of a—plan,local law,ordinance;„ ...... — v
admini W—Afive rule,olr regulatioe? — ES
I f Yes,attach,a narl ve description writhe iritent of the piropose:d action and the env ironmental resource$ that
May be affected in the municipality and proceed to Part 2. If no,continue to question 2..
-.........—
2. Dolies the proposed aQticrn require a perrniL approval or funding from any;iherovomm—ry? NO
entalAgni
IfYies, list agency(s)nameand permit or approval, � VES
NYSDEC
1a.Tota:I acreage of the site of the proposed action,'?
bl. Total acreage to be physically disturbed? acres
c.Total acreage(pirl site and any configuousproperties)owned
or controlled by the applicant or project spansor? 2.93 acres
4. Cheek all land usos that occur on,adjoining and near the proposed action.
t3 Urban E]'Rural(non-qgriculture) ElIndustrial []Cornm. l OResidentiall(sublurban)
OForest ElAgriculture EliAquatic 00ther(specify):
OParkland
Page I of 3
5. Is the proposed action, NO, �YMU�S_ NIA
F_au..A permitted use underl the zoning regulationO
b. Consistent with the adopted comprehensive plan?
6, Is theproposed action Wnaistentwith the pTedoniinant charaeterof the—existingbuiltair—n—atural ......—NO —Y'"K—S
landscape? I
L—i 21
7, Is the site of the proposed,action—kated in,or does it adjoin,a state listed Critical Environmental Area?' NO YES
If Yes,identify.
a. Will'the proposed action result:in a substantial increase in traffi—u 'above present levels? NO YES
b.Are public transportation service(s)available at oT near the site of the proposed action?
c.Are any pedestrian accommodations or bicycle routes avai labile on or near site of the proposed action?
9- Does the proplased action i�eet—orexceed the State enoTgy code requirements? NO YES,
If the the
actiort will exceed reqairernents,describe design.features and technologies.
10'. Will-the—proposed actionconnect to an existing public/privatic water supply? NO, YES
If No,describe method.for providing potable water.
11.Will the proposed action connect to existing wastewat—cru"filitiles? YES
If No,describe method'for providing wastewater treatment El W7
—1 .—aDoc�,lthe site cola structure;that is listed on either the State or Natio—n a"l Register—of Ifistorri c——N 0"" YE S
Places?
L Is the proposed action.located in an archeological sensitive area?
13,a. Does,any portion ofthesite of the proposed action,or lands adjbining the proposed Action,contain NO YES
wetlands or ether waterbodies regulated by a federall, state or local agency?
b.Would die proposed action physically alter,o�r encroach into,any existing wetland or waterbody'.)
If Ye identify the wetland or watorbody and extent of alterations insquare feet or acres.-
14 Identify the typical habitat typies.that occur on,,or are likely to be found loin the project sate. heck all that apply,
y,Shoreline 0 Forest: Agricultural/grasslan6 Early mid-successional,
El Wetland. 0 Urban Suburban
15.Does the Site of the proposed action contain any species of animal,or associated habitats, listed --Fq-0 YES,
by the Stats::or Federal government as threatened or endangered? —E
� EL
161. Is the project site located in the 101,01 year ffr r1 plain? NO YES
IT Will the proposed action create storm water discharge, eithor from point ornol—sources? NO VES
If Yes,
a. Wil I storm water discharges flow to,adjacent:properties? 0 NO, DYES Li
be Will stonn water discharges be directed to cstabliqhed conveyance systems(runoff and storm drains)'i'
If Yes, briefly describe, NO OYES
Page 2, of 3
18, Does the:proposed action includc coRstruction or other activities that result in the inapoundrnvnt of RT( -�FE-S—
water ar-other liquids(e., . reteiition pond,waste lagoon,dam,)?
If Yes, explain purpose and size:
19.Has the site of the proposed action or an adjoinirtg property been the location of an active or closed NO YES
sollid waste management facj]W,
If Yes, describe:
201.11as the site of the proposed action or an adjoining property been the wbjcct of remediation(ongoing or NO, YES
completed)for hazardous waste?
If Yes,describle.
I AFFIRM TFIAT—THE IIS FO —PROVIDED�ABOVE IS TWUE,uND ACCURATE TO TRE REST OF M'
KNOWLEDGE
Apphcant/sponsw)r jai c: Mike Lewis Date:Aug 14,,2017
sigthatuire,
PRINT FMS�� Page,3 of 3
Agency Use Only [If applicable)
Project:
Date.
Short Environmental Assessment Form
Part 2' -Impact Assessment
Pxrt 2 is to be completed by the Lead Agency.
Answer ail of the following questions in.Part,2 using the infonnation contained in part I and other materials submitted by
the project sponsor or otherwise available to the mviewer. When answering the questions the reviewer should be guided by
the concept"Have my responses been reasonable considering the scale and context of the proposed action?"
Ne,or Moderate
small to large
impact impact
may may
....... OCCur Otclir
Will :Fe-P-i�P—OSedaction7FTiit—ea iiiG con flici'Wth—an ad;�i;7d land use plan or zoning
regulations?
2, Will the proposed action result in a change in the use or intensity of wm of land?
I Will the Proposed action impair the character or quality of the existing comu
mnity?
El
Li
will tlic
d a0ion have animpact on the environmental characteristics that caused the
establishment of a Critical Environmental Area(CEA)?
5. Will the proposed.action result in an adverse,change in the existing level of traffic or E]
affect existing infrastructure for mass transit, biking or walkway? 01 1:1
.......... —--—--------
6. Will the:proposed action cause an increase in the use ofenerSy and it tails to incorporate:
r9so ably avai labl,.e2LTU co�scrvafionor renewable energy opporw
— 1_ _ _ ——" nitics?
7Will the Proposed action impact existilig':
a®public/Private water supplies? El
b.public/prMte wastewater treatment utilities'? El
8, Will t�he pposed action impair the character or quality of impa
ortant historic, rchaeatogical,
architecturalroOr aesthetic resources?
U
..........
9. Will the proposed action result in an,adverse change to natural resources ('e.g,,, wolands,
waterbodics,groundwater,air quality,flora and fauna)?
Wi I I the proposed action mutt in an increase in the potential for erosion, flooding or drai
ProblelTis? Inage
..... -—
�. ,
Wjscd ------
acl.i"on create a hazard to,environmental resources or human health? El
PRINT FORM P,a,ge 1 of'2
A aim Use Only[If apIlicable)
Rrojtct,
Date;
Short Environmental Assessment Form
Part 3 Determin4tion of Significance
F'Ofevery question in Pail 2 that was answered"moderate w large impact may occur",oT if there is meed to explain why a
particular element of the proposed action may or will not result in,a significant adverse environmental impact, please
complete Part I Part 3 should,in sufficient detail,idenfif�the impact,including anmeasure-s or design elements that
y
have been included by the project sponsor to avoid or reduce impacts. Part 3 should also explain how the lead agency
determined that the impact may or will not be significant,Each patontial impact should be asse.ssod considering its,setting
probability of occurring,duration,irreversibility,geographic scope and magnitude- AI&o consider the potential for short-
ter , Flong�term.and cumulative impacts,
Check this box if you have detennined,based On the information and analysis,above, and any supporting documentation,,
Chant the proposed action may Tesult inone or more potentially large,or significant adverse impacts and an
environmental impact statement is required'.
Check.this,box if you have deter!nalned, based on the information and analysis,above, and any supporting documentation,
that the proposed action will not result in any significant adverse environmental impacts.
'Name of LoadAgency Date
Print or I�po Name of Responsible Officer in Lead Agency Title of Responsible Officer
Signat=of Responsible Officer ire;Lead Agency Signature of Prepaxer('if different ftorn Resp=4bie Of cor)
INTFORM
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