Site Plan Application RAN ENTERTAINMENT —T — ADDITIONAL, PARKING
TOWN OF QUEENSBURY
Site Plan Review Application
Review Process:
1. Required Pre-submission meeting with staff to determine general completeness to be held no later than 1
week pirior to deadline dal. Call (518) 761-8265 or(518) 761-8220 for an appointment.
2. Submittal of complete application: 1 original and 14 copies of the application package by monthly deadline.
3. Determination of application completeness. All necessary information must be provided and appropriate
fee(s)paid for consideration for placement on an agenda for that month.
4. Incomplete a lications will not be considered for_placement on any agenda until all missing
information has been submitted.
5. Submittal to Warren County Planning, if applicable.
6. Planning Board meeting, generally the third & fourth Tuesday of each month. You will be advised in
writing as to which meeting to attend.
7. Following the meeting you will be provided with a copy of the resolution stating the Board's decision on
your application. If your application was approved, the next likely step is a Building Permit. Final
drawings must be provided for the next phase of review. If your application was denied, your project cannot
proceed as submitted.
DOCUMENTATION REQUIREMENTS hard copy & electrwonic :
Please submit 1 ori final & 14 copies,of the completed application package to include:
Completed Application pages 2-9, signed& dated
Pre-Submission Meeting totes:, signed by staff
• Copy of Deed
Checklist & Plot Plan
Environmental Assessment Form for any non-residential project
r Fee: $100 (0 — 10,000 sq. ft.); $250 (10,001 — 30,000 sq. ft.); $500 (30,001 -100,000 sq. ft.); $1,000
(100,000+ sq. ft.)
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Staff& Contact Information:
Craig Brown, Zoning Administrator craigbkqueensbufy.net
Laura Moore, Land Use Planner lin,00t-e o-b ucensbu .net
Sunny Sweet, Office Specialist—Planning sunn s(), ueensbu .net (518) 761-8220
Visit our website at wwww, ueenslaui .net for further information and forms
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Site Plan Review application—Revised October 2016
Town of Queensbury Planning Office-742 Bay Road,Queensbury,NY 12804
General Information
Tax Parcel ID Number: 309.13-2-28
Zoning District: Commercial Light Industrial
Lot size: 3.86 acres
Detailed Description of Project [includes current&proposed use]:
spaces.
Location of project:
south side of Corinth/road opposite Connecticut Ave.
Applicant Name: RAN Entertainment,LLC Address: 168 Reynolds Road,Ft.Edward,NY
Home Phone 518-743-0504 Cell: 518-365-3735
..........................._..-. ............................... .__.... .......................... ....
Work Phone 518-365-3735 Fax 518-743-1080
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E-Mail: rrsaunders@verizon.net
Agent's Name: Nace Engineering, PC Address: 169 Haviland Road,Queensbury,NY
Home Phone Cell; 518-796-1173
Work Phone Fax
518-745400 518-792-8511
E-mail
tom@1-survey.com
Owner's Name Address
SAME AS APPLICANT
Home Phone Cell
Work Phone Fax
E-mail
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Site Plan Review application—Revised October 2016
Town of Queensbury Planning Office-742 Bay Road,Queensbury,NY 12804
Site Development Data.
Area /Type Existing sq. ft. Proposed Total sq. ft.
Addition s . ft.
A. Building footprint 22,220 d 22,220
_..--ac---.�.......Gar..�........ ............�......�.........................................
B. Dettacheed age 0 0 0
C. Accessory Structure(s) 0 375 375
D. Paved, gravel or other hard surfaced area 34,493 7,513 42,006
E. Porches/Decks 0 0 0
.......... ..............................
F. Other 0 0 0
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G. Total Non-Permeable [Add A-F] 56,713 7,888 64,601
H. Parcel Area [43,560 sq. ft./acre]
168,180 1.68 1..80...................................... ....... 168,180
I. Percentage of Impermeable Area of Site [I=G/H] 33.7% 38.4%
SetbackRequirmeat
Area Required ExistingProposed
Front[1] 75 156.2 156.2
Front [2]
.............
Shoreline
Side Yard [1]
30 91.7 91.7
. ......,
Side Yard [2] 30 30.6 30.6
__WWW_WWW
Rear Yard [1] 30 363.2 363.2
Rear Yard [2]
Travel Corridor 1 75 156.2 156.2
Height [max] 60 45+/- 45+/-
Permeability 30% 66.3% 61.6%
.....................................
. __WW
No. of parking spaces 112 78 112
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Site Plan Review application-Revised October 2016
Town of Queensbury Planning Office-742 Bay Road,Queensbury,NY 12804
Additional Projectinformation
1. Will the proposal require a Septic Variance from the Town Board of Health? NO
2. If the parcel has previous approvals, list application number(s): PZ149-2016
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 4/15/2018 End Date 4/30/2018
5. Estimated total cost of project: $5,000
mmmmmmm
6. Total area of land disturbance for project: 10,000 sq.ft.
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]
_WWW
Waterfront Residential WR 0.22
Commercial Moderate/Intensive CM/CI 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 (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 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 sq. ft.
B. Existing Floor Area sq. ft. [see above definition
C. Pro osed Additional Floor Area sq. ft.
D. Proposed Total Floor Area sq. ft.
E. Total Allowable Floor Area (Area x ) see above table
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*If D is larger than E. a variance or revisions to your plan may be needed. Consult with Staff.
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Site Plan Review application—Revised October 2016
Town of Queensbury Planning Office-742 Bay Road,Queensbury,NY 12804
Revised June 2009
S 179-9-080 ReggiLrements for Site Plan A I'r vaL The Planning Board shall not approve a Site Plan
unless it first determines that such site plan meets the following Standards. Please prepare responses to each of
the following topics.
._......... .......
STANDARDS _............................_._....__....
A. The proposed project furthers or is consistent with the policies ......... W WWW
of thee Town's Comprehensive Plan.
FURTHER COMMERCIAL DEVELOPMENT ALONG EXISTING MAJOR CORRIDOR
B, .The proposed project complies with all other requirements of this Chapter, including the site plan review standards as set forth in
Paragraph F of this section,the dimensional, bulk, and density regulations of the zoning district in which it is proposed to be located
(Article 3 and Table 1),the applicable requirements of all other Articles that apply.
PROPOSED DEVELOPMENT COMPLIES WITH TOWN'S ZONING AND SITE PLAN REQUIREMENTS
C. The site plan encourages pedestrian activity internally and, if practicable, to and from the site with pedestrian paths or sidewalks
connected to adjacent areas.
ANY PEDESTRIAN CONNECTION WILL DEPEND ON WARREN COUNTY PROVIDING SIGNALIZED
CROSSWALK ON CORINTH ROAD TO CONNECT SITE TO EXISTING SIDEWALK ON NORTH SIDE
----. ...............
.
D. The site plan must conform to Chapter 136 Sewage and Sewage Disposal, Chapter 147 Stormwater Management Local Law, and
other applicable local laws.
PROPOSED TO BE SERVED BY MUNICIPAL SEWER
._..._.......................................
E. The proposed use shall be in harmony with the general purpose or intent of this Chapter, specifically taking into account the location,
character and size of the proposed use and the description and purpose of the district in which such use is proposed,the nature and
intensity of the activities to be involved in or conducted in connection with the 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.
PROPOSED USE IS CONSISTENT WITH THE EXISTING ZONING AND USES ALONG CORRIDOR
F. The establishment,maintenance and operation of the proposed use will not create public hazards from traffic,traffic congestion or the
parking of vehicles and/or equipment or be otherwise detrimental to the health, safety or general welfare of persons residing or
working in the neighborhood or to the general welfare of the town. Traffic access and circulation, road intersections, road and
driveway widths,and traffic controls will be adequate.
PROPOSED USE HAS MINIMAL TRAFFIC IMPACT
G. Off-street parking and loading facilities will be appropriately located and arranged and sufficient to meet traffic anticipated to be
generated by the new use. The establishment of vehicle links between parking areas of adjacent properties are provided where
feasible. This furthers the Town's goal of reducing curb cuts and reducing congestion.A twenty-foot wide connection is required. If
adjacent properties are either undeveloped or previously developed without having made prdvision for future linkage, 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 property owners for purposes of coordinating
linkages with adjacent properties.
PROJECT HAS ADEQUATE ON-SITE PARKING FOR PROPOSED USE
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H. The project shall not have an undue adverse impact upon the natural, scenic, aesthetic, ecological, wildlife, historic, recreational or
open space resources of the town or the Adirondack Park or upon the adequate provision of supporting facilities and services made
necessary 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 hereunder, the Planning Board shall consider those factors pertinent to the project
contained in the development considerations set forth herein under§ 179-9-080 of this chapter, and in so doing,the Planning Board
shall make a net overall evaluation of the project in relation to the development objectives and general guidelines set forth in§ 179-9-
080 of this Article.
PROPOSED USE HAS NO SIGNIFICANT IMPACT ON NATURAL OR SCENIC RESOURCES
Town of Queensbury Planning Office- 742 Bay Road • Queensbury, NY 12804 • 518-761-8220
_ Revised June 2009
I. The provision for and arrangement of pedestrian traffic access and circulation, walkway structures, control of intersections with
vehicular traffic and overall pedestrian convenience shall be safe and adequate for pedestrian movement. Pedestrian connections
between adjacent sites shall be provided to encourage pedestrian use,
SEE "C"ABOVE
J. Stormwater drainage facilities will prevent an increase of post development drainage flows as compared to pre-development drainage
flows. Drainage of the site shall recharge ground water to the extent practical. Surface waters flowing off-site shall not degrade any
streams or adversely affect drainage on adjacent properties or public roads. Facilities shall be in conformance with the drainage
standards of Chapter 147 of the Town Code and the Town of Queensbury Subdivision Regulations where applicable.
ALL STORMWATER DRAINAGE TO BE MAINTAINED ON SITE
K. The water supply and sewage disposal facilities will be adequate and will meet all applicable and current requirements set forth by
Department of Health regulations and Chapter 136 of the Town Code.
MUNICIPAL WATER AND SEWAGE ARE TO BE USED
L. The adequacy, type and arrangement of trees, shrubs and other suitable plantings, landscaping and screening shall effectively
provide a visual and/or noise buffer between the applicants and adjoining lands, including the maximum retention of existing
vegetation and maintenance, including replacement of dead or deceased plants.
PROPOSED LANDSCAPING TO MEET TOWN REQUIREMENTS. UNUSED AREA TO REMAIN WOODS
M. Fire lanes, emergency zones and fire hydrants will be adequate and meet the needs and requirements of emergency service
providers.
EMERGENCY ACCESS PROVIDED
N. The design of structures, roadways and landscaping in areas susceptible to ponding, flooding and/or erosion will minimize or avoid
such impacts to the maximum extent practicable.
VERY POROUS SOILS-ALL DRAINAGE HANDLED ON SITE
O. The site plan conforms to the design standards, landscaping standards and performance standards of this chapter.
SITE PLAN COMPLIES WITH ZONING CODE
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Town of Queensbury Planning Office- 742 Bay Road • Queensbury, NY 12804 • 518-761-8220
§ 179-9-050 Checklist-Application for Site Plan Review.
Application materials 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 items A-V. The
applicant may request a waiver from A-V and is to provide reasons for waiver(s) requested. Please label
information to be submitted.
REQUIREMENTS __WWW.ww Sheet#
A. A vicinity map drawn at the scale that shows the relationship of the proposal to existing community facilities which affect
or serve it,such as roads,shopping areas,schools,etc. The map shall also show all properties,identify owners, SP-1M
subdivisions,streets and easements within 500 feet of the property. Such a sketch may be superimposed on a United States
Geological Survey map of the area.
B. The site plan shall be drawn at a scale of forty feet to the inch(1"=40 feet)or such other scale as the Planning Board may
deem appropriate,on standard 24"x 36"sheets,with continuation on 8 1/2"x 11"sheets as necessary for written SP-1M
information. The information listed below shall be shown on the site plan and continuation sheets.
C. Name of the project,boundaries,date,north arrow,and scale of the plan. SP-1M
D. Name and address of the owner of record,developer,and seal of the engineer,architect or landscape architect. If the SP-IM
applicant is not the record owner,a letter of authorization shall be required from the owner,
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E. The location and use of all existing and proposed structures within the property,including all dimensions of height and SP-IM
floor area,all exterior entrances,and all anticipated future additions and alterations.
...........
F. The location of all present and proposed public and private ways,off-street parking areas,driveways,outdoor storage areas,
sidewalks,ramps,curbs,paths,landscaping,walls and fences. Location,type and screening details for all waste disposal SP-1M
containers shall also be shown.
Cr The location,height,intensity and bulb type(sodium,incandescent,etc.)of all external lighting fixtures. The direction of NA
illumination and methods to eliminate lare onto ad'oinin ro erties must also be shown in com fiance with¢ 179-6-020.
H. The location,height,size,materials and design of all proposed signs. NA
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1 The location of all present and proposed utility systems including: SP-2M
1. Sewage or septic system;
2. Water supply system;
3. Telephone,cable and electrical systems;and
4. Storm drainage system including existing and proposed drain lines,culverts,catch basins,headwalls,endwalls,
hydrants,manholes and drainage swales.
J Plans 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 Stormwater Pollution Prevention Plan(SWPPP)for all land development SP-2M
activities(excluding agricultural activities)on the site that results in land disturbance of one acre or more. A SWPPP shall
comply with the requirements of the DEC SPDES MS-4 General Permit and Chapter 147 of the Town of Queensbury
Code. It shall be at the discretion of the Planning Board as to whether a SWPPP or an erosion and control plan shall be
required for a site plan review project land disturbance of less than one acre.
K _ Existing and proposed topography at two-foot contour intervals,or such other contour interval as the Planning Board shall
allow. All elevations shall refer to the nearest United States Coastal and Geodetic Bench Mark. If any portion of the parcel SP-2M
is within the 100-year floodplain,the area will be shown and base flood elevations given. Areas shall be indicated within
the proposed site and within 50 feet of the proposed site where soil removal or filling is required,showing the approximate
volume in cubic yards.
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L. A landscape plan showing all existing natural land features than may influence the design of the proposed use such as rock NA
outcrops,stands of trees,single trees eight or more inches in diameter,forest cover and water sources and all proposed
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changes to these features,including sizes and types of plants. Water sources include ponds,lakes,wetlands and
watercourses,aquifers,floodplains and drainage retention areas.
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M. I Land Use District boundaries within 500 feet of the site's perimeter shall be drawn and identified on the site plan,as well
as any Overlay Districts that apply to the property, SP-1M
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Site Plan Review application—Revised October 2016
Town of Queensbury Planning Office-742 Bay Road,Queensbury,NY 12804
................
REQUIREMENTS (CONTINUED)
Sheet#
N Traffic flow patterns within the site,entrances and exits,loading and unloading areas,as well as curb cuts on the site and SPAM
within 100 feet of the site. The Planning Board may,at its discretion,require a detailed traffic study for large developments or
for those in heavy traffic areas,which shall include:
1. The projected number of motor vehicle trips to enter or leave the site,estimated for weekly and
annual peak hour traffic levels;
2. The projected traffic flow pattern including vehicular movements at all major intersections likely
to be affected by the proposed use of the site;
3. The impact of this traffic on levels of service on abutting public streets and at affected
intersections. Existing and proposed weekly and annual peak hour traffic levels and road capacity
levels shall also be given.
For new construction or alterations to anstructure,a table containingthe following information shall be included: mm
OwF� ... y... � ....... ......_ .__. g._._... .....m ... ...... uded: NA
1. Estimated area of structure to be used for particular purposes such as retain operation,office,
Storage,etc.;
2. Estimated maximum number of employees;
3. Maximum seating capacity,where applicable;and
4. Number of parking spaces existing and required for the intended use.
P 1. Floor Plans.
NA
2. Elevations at a scale of one-quarter inch equals one foot(1/4"= 1 foot)for all exterior facades of the proposed structure(s)
and/or alterations to or expansions of existing facades,showing design features and indicating the type 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
mitigate project impacts. NA
R. Plans for disposal of construction and demolition waste,either on-site or at an approved disposal facility, NA
S Plans for snow removal,including location(s)of on-site snow storage. SP-2M
T. An Environmental Assessment Form("EAF")as required by the SEQRA regulations,with Part 1 completed by the Applicant NA
shall be submitted as part of the application. If the proposed project requires a special use permit and an EAF has been
submitted in conjunction with a special use permit application,a duplicate EAF is not required for the site plan application.
U. If an application is for a parcel or parcels on which more than one use is proposed,the applicant may submit a single NA
application for all such uses,provided the proposed uses are accurately delineated on a site plan drawn pursuant to the
requirements set forth above. The Planning Board may grant the application with respect to some proposed uses and not
others. For purposes of reviewing an application(and for SEQRA compliance)all proposed uses on a single parcel or on
contiguous parcels shall be considered together.
www_ ............_
`I A brief narrative statement on how the project proposed for review furthers or is consistent with the vision,goals and policies
in the Town's Comprehensive Plan. 7NARRAT
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Site Plan Review application—Revised October 2016
Town of Queensbury Planning Office-742 Bay Road,Queensbury,NY 12804
Town of Queensbury Site Plan Pre-Submission Conference Form / Section 179-9-040
1. Applicant Name: RAN Entertainment,LLC
2. Tax Map ID 309.13-2-28 Location: south side Corinth Road
3. Zoning Classification CLI
4 i
4. Reason for Review: � t°' J'e-) c,(AL ° :b:.i ;.., . . �'�` ��i�s'1. ,�' i /I
5. Zoning Section#: . P °'s,.o to
6. Pre-Submission Meeting Notes: Provided Outstanding; Please provide by
Deed
General Information complete
Site Development Data Complete s�
Setback Requirements Complete
Additional Project Information Complete
FAR addressed
Requirements for Site Plan-Standards
Checklist items addressed
Environmental Form completed ,i , ITIT i'e. (f
CAITITIT d ��L `�
Signature Page completed
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,
$ C 0 ev t i
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'r
Staff Representative:
Applicant/Agent: . .. - Date: ...
8
Site Plan Review application—Revised October 2016
Town of Queensbury Planning Office-742 Bay Road,Queensbury,NY 12804
Signature Page
This page includes the 1.)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 documentation required.
OWNER'S AGENT FORM:
Complete the following if the OWNER of the property is not the same as the applicant
Owner: RAN Entertainment,LLC
Designates: Nace Engineering,PC
As agent regarding: Variance XX Site Plan Subdivision
For Tax Map No.: Section -2—,Block Lot
Deed Rcferei a: Book Pae Date
OWNER SIGNATURE: "� DATE.
APPLICANT'S AGENT FORM:
Complete the following if the APPLICANT is unable to attend the meeting or 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 Page Date
OWNER SIGNATURE: DATE:
2.). FN{NINIi,FRIN(" IicsE ID1SdCLOSIJRE: Applications may be referred to the 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$ 1,000 without notification to the applicant.
3. AI JTIJ0R1ZA"I'ION [,OR SITE VISITS.- By signing this page and submitting the application materials attached herein,the Owner,Applicant,
and his/her/their agent(s) hereby authorize the Zoning Board or Planning Board and Town Staff to enter the subject properties for the purpose of
reviewing the application submitted.
()TIIER PERMIT ISI^:4I'ON tiIIIII IT S: Other permits may be required for construction or alteration activity subsequent to approval by the
Zoning Board or Planning Board. It is the applicant's responsibility to obtain any additional permits.
5. OFFICIAL MEETING MINUTES DISCLOSI,lI+E: 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 from those tapes constitutes the official
record of all proceedings.
6. A(.RFEMEN"I'"I"O P 2OVII)E DO('tl&I EN'I"A"I'ION RI' tJIREI): I,the undersigned,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 the 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 approved plans and in 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
I/we may be required to provide an as-built survey by a licensed land surveyor of all newly constructed facilities prior to issuance of a certificate of
occupancy
I have read and agree to the above.
,1
St SII"cil,ltr)� , ' ;..,� _a...�e Pliant] �I3�a s®gned..
Sagtit]�e Agent- Print Name [Agent] Date signed
9
Site Plan Review application—Revised October 2016
Town of Queensbury Planning Office-742 Bay Road,Queensbury,NY 12804
Short Environmental Assessment Form
Part 1 -Project Information
instructions for Completing
Part 1 -Project Information. The applicant or project 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 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 possible based on current information.
Complete all items in Part 1. 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.
____...-______...................... W
Part 1 -Project and Sponsor Information
Name of Action or Project:
SKY ZONE-ADDITIONAL PARKING
............................
Project Location(describe,and attach a location map):
SOUTH SIDE CORINTH ROAD OPPOSITE CONNETICUT AVE.
...............
Brief Description of Proposed Action:
CONSTRUCT AN ADDITIONAL 34 PARKING SPACES FOR EXISTING SPORTS/AMUSEMENT FACILITY
Name of Applicant or Sponsor: Telephone: 518-3653735
RAN ENTERTAINMENT,LLC E-Mail: rrsaunders@verizon.net
Address:
168 REYNOLDS ROAD
City/PO: State: Zip Code:
FT.EDWARD NY 12828
1.Does the proposed action only involve the legislative adoption of a 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 environmental resources thatFv-(] El
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 or approval:
. g
3.a. Total
b. Total acreage to bephysically e d stu bed actions 30.2 acres
acreageproposed
g � 3 acres
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c.Total acreage(project site and any contiguous properties)owned
or controlled by the applicant or project sponsor? 3.68 acres
4. Check all land uses that occur on,adjoining and near the proposed action.
❑Urban ❑Rural(non-agriculture) []Industrial mCommercial m Residential(suburban)
E3 Forest ❑Agriculture El Aquatic ❑Other(specify):
❑Parkland
Page 1 of 3
_µ
proposed YES N/A
5. Is the ro osed action, NO
a.A permitted use under the zoning regulations? ❑ W1 1:1'
.....
b.Consistent with the adopted comprehensive plan? ylr
6. Is the proposed action consistent with the predominant character of the existing built or natural NO YES
landscape? 1:1 Z
7. Is the site of the proposed action located in,or does it adjoin,a state listed Critical Environmental Area? NO YES
If Yes, identi
fY ..........
8. a.Will the proposed action result in a substantial increase in traffic above.................
ITpresent levels? NO YES
b.Are public transportation service(s)available at or near the site of the proposed action?
c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action? 71 0
9.Does the proposed action meet or exceed the state energy code requirements? NO YES
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 YES
If No,describe method for providing potable water:
YJ
11.Will the proposed action connect to existing wastewater utilities? NO YES
If No,describe method for providing wastewater treatment: 21
12. a.Does the site contain a structure that is listed on either the State or National Register of Historic NO YES
Places? Z
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? Z
EL
b. Would the proposed action physically alter,or encroach into,any existing wetland or waterbody? El
If Yes, identify the wetland or waterbody and extent of alterations in square feet or acres NSI
14. Identify the typical habitat types that occur on,or are likely to be found on the project site. Check all that apply:
❑Shoreline ❑Forest ❑Agricultural/grasslands []Early mid-successional
❑ Wetland ❑Urban m Suburban
15. Does the site of the proposed action contain any species of animal,or associated habitats,listed NO YES
by the State or Federal government as threatened or endangered?
16. Is the project site located in the 100 year flood plain? NO YES
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✓ '
17. Will the proposed action create storm water discharge,either from point or non-point sources? NO YES
If Yes,
a.Will storm water discharges flow to adjacent properties? ❑NO ❑YES
b.Will storm water discharges be directed to established conveyance systems(runoff and storm drains)?
If Yes,briefly describe: FINO DYES
Page 2 of 3
....... ........
18.Does the proposed action include construction or other activities that result in the impoundment of NO YES
water or other liquids(e.g.retention pond,waste lagoon,dam)?
If Yes,explain purpose and size
19. Has the site of the proposed action or an adjoining property been the location of an active or closed NO YES
solid waste management facility?
If Yes,describe:
_...�
20.Has the site of the proposed action or an adjoining property been the subject of remediation(ongoing or NO YES
completed)for hazardous waste?
If Yes,describe:
.. _ .......... .._._....�............� ............. ._..................... ....._._._._........................._......
I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY
KNOWLEDGE
pp p , N nme 3 :_.. � :'..� IVt N Nt,,e- Date:.._. ... .
Signature:
l .
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Project:
Date:
Short Environmental Assessment Forst
Part 2 -Impact Assessment
Part 2 is to be completed by the Lead Agency.
Answer all of the following questions in Part 2 using the information contained in Part 1 and other materials submitted by
the project sponsor or otherwise available to the reviewer. 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?"
...................................... ............................... ..................... .............,-___.....__,.
No,or Moderate
small to large
impact impact
may may
..._...........
occur occur
1. Will the proposed action create a material conflict with an adopted land use plan or zoning
regulations? 1-1 El
2. Will the proposed action result in a change in the use or intensity of use of land? El 7
W
3. Will the proposed action impairthecharacter or quality of the existing community? F-1 El
4. Will the proposed action have-----
an impact 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
affect existing infrastructure for mass transit,biking or walkway?
...............................M �........................... ......................................._.._ ...... ............
6. Will the proposed action cause an increase in the use of energy and it fails to incorporate
reasonably available energy conservation or renewable energy opportunities?
.....................
7. Will the proposed action impact existing: ❑ E
a.public/private water supplies?
b.public/private wastewater treatment utilities? El
8. Will the proposed action impair the character or quality of important historic,archaeological, '
architectural or aesthetic resources? El El
9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands,
waterbodies,groundwater, air quality,flora and fauna)?
10. Will the proposed action result in an increase in the potential for erosion,flooding or drainage p lp
problems? E
11. Will the proposed action create a hazard to environmental resources or human health?
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Part 3 Determination of Significance
For every question in Part 2 that was answered"moderate to large impact may occur",or if there is a need to explain why 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. Part 3 should also explain how the lead agency
determined that the impact may or will not be significant.Each potential impact should be assessed considering its setting,
probability of occurring,duration,irreversibility,geographic scope and magnitude. Also consider the potential for short-
term,long-term and cumulative impacts.
that theCheck proposed box if
sedyo tion may inednbased on the information and analysis above,and any supporting documentation,
one or more potentially large or significant adverse impacts and an
environmental impact statement is required.
Check this box if you have determined,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 Lead Agency g y Date
Print or Type Name of. _ ........ .....-- .._.....
. .
yp Responsible Officer in Lead Agency Title of Responsible Officer
Signature of Responsible Officer in Lead Agency Signature of Preparer(if different from Responsible sp e Officer)
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