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Site Plan and cover letter New Beginnings Community Church . . . where life changing miracles happen." May 14, 2019 TO WHOM IT MAY CONCERN, The change of use request for the church property to add an outdoor dining area to our footprint to better serve the public. This seating area to include a concrete pad 20' x 27'6" and 20' x 17'6" each on the side of existing sidewalk for entering building the completed commercial kitchen and adjoining dining room. The dining area is to be 3 season patio to be covered by a carport kit 20' x 50' that will come with clear vinyl gable ends and clear vinyl sides designed to be rolled up and down according to conditions. If gutters are deemed necessary, the piping to convey rain water are right by new canopy. The canopy cover and sides to be removed for winter. The only alteration for seating people will be to reduce indoor seating inside to 18 people and add 27 seats to the patio for approved number of 45 seats. The existing booths will be the indoor seating for the rest of the indoor seating. MISSION STATEMENT FOR THE DIX AVENUE DINER, LLC.: Hippocrates said: "Let food be thy medicine and medicine be thy food" This Diner will be Farm to Fork sourcing local ingredients grown sustainably producing meals that will inspire health and wellness while building community and the local economy. The Diner will provide informational outreach using social media platforms to patrons addressing chronic health crises of obesity, diabetes, heart disease and cancer thru knowledge paths outside of the standard of care to assist patrons taking control of their health. Sincerely, Pastor Randy D. Gross Church Phone 518-307-6574 487 Dix Avenue Queensbury,N.Y. 12804 Randy D.Gross,Pastor t TOWN OF QUEENSBURY , i 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 prior to deadline day. 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 applications 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 & electronic): Please submit 1 original & 14 copies of the completed application package to include: • Completed Application pages 2-9, signed& dated • Pre-Submission Meeting Notes: signed by staff • Copy of Deed • Checklist & Plot Plan • Environmental Assessment Form for any non-residential project • 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.) Staff& Contact Information: Craig Brown, Zoning Administrator craigb(&Aueensburv.net Laura Moore, Land Use Planner lmoore(&Nueensbury.net Sunny Sweet, Office Specialist—Planning sunnys(aqueensburv.net (518) 761-8220 Visit our website at www.queensbury.net for further information and forms 1 Site Plan Review application—Revised October 2016 Town of Queensbury Planning Office-742 Bay Road, Queensbury,NY 12804 General Information Tax Parcel ID Number: 303.16-1-33 Zoning District: CM Lot size: 15.29 +/-acres Detailed Description of Project [includes current&proposed use]: Construct 20'x 45'concrete patio with temporary awning cover for seasonal outdoor dining seating+ install 9'x 13'walk-in cooler. Location of project: 487 Dix Av,east of intersection of Queensbury Ave.&Dix Ave. Applicant Name: Address: Randy Gross 487 Dix Avenue Home Phone Cell: 518-307-6574 Work Phone Fax 518-792-6674 E-Mail: dixavediner@gmail.com Agent's Name: Address: 169 Haviland Road Hutchins Engineering Queensbury NY 12804 Home Phone Cell: Work Phone Fax (518) 745-0307 (518) 745-0308 E-mail thutchins@hutchinsengineering.com Owner's Name Address same as applicant Home Phone Cell Work Phone Fax E-mail 2 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 sq. ft. A. Building footprint 11,284 11,284 B. Detached Garage C. Accessory Structure(s) D. Paved, gravel or other hard surfaced area +900 for patio 106,193 -230 for sidewalk 106,863 E. Porches/Decks F. Other Walk-in Cooler 0 +117 +117 G. Total Non-Permeable [Add A-F] 117,477 787 118,264 H. Parcel Area [43,560 sq. ft. /acre] 666,032 0 666,032 I. Percentage of Impermeable Area of Site [I=G/H] 17.64% 0.12% 17.76% Setback Requirements Area Required Existing Proposed Front [1] 50 +/-364' +/-364' Front[2] N/A N/A N/A Shoreline N/A N/A N/A Side Yard [1] 30'(East) ±209' ±209' Side Yard[2] 20'(West) ±260' ±260' Rear Yard [1] 20' ±80' ±80' Rear Yard [2] N/A N/A N/A Travel Corridor N/A N/A N/A Height [max] 40' N/A <40' Permeability 30% +/-83% +/-80% No. of parking spaces 78 236 236 4/2/19 NYS Department of Health letter limits the restaurant to 45 seats total 3 Site Plan Review application—Revised October 2016 Town of Queensbury Planning Office-742 Bay Road,Queensbury,NY 12804 Additional Project Information 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): CM 3. Does this project require coverage under the New York State Pollutant Discharge Elimination System (SPDES) Permit Program? 4. Estimated project duration: Start Date End Date 5. Estimated total cost of project: 6. Total area of land disturbance for project: 20'x 45' 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/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. . rcel Area sq. ft. B. Existing Floor Ar s . ee above definition] C. Proposed Additional Floor Area — sq. ft. D. Proposed Total Floor Area sq. ft. E. Total ale Floor Area (Area x e above table] *If D is larger than E. a variance or revisions to your plan may be needed. Consult with Staff. 4 Site Plan Review application—Revised October 2016 Town of Queensbury Planning Office-742 Bay Road,Queensbury,NY 12804 § 179-9-080 Requirements for Site Plan Approval. 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 of the Town's Comprehensive Plan. 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. 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. D. The site plan must conform to Chapter 136 Sewage and Sewage Disposal,Chapter 147 Stormwater Management Local Law,and other applicable local laws. 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. 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. G. Off-street parking and 19oading 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 provision 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. 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. 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. 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. 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. 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. M. Fire lanes,emergency zones and fire hydrants will be adequate and meet the needs and requirements of emergency service providers. 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. O. The site plan conforms to the design standards,landscaping standards and performance standards of this chapter. 5 Site Plan Review application—Revised October 2016 Town of Queensbury Planning Office-742 Bay Road,Queensbury,NY 12804 Applicant/Owners: Randy Gross Location: 487 Dix Ave. & Tax Map ID# 303.16-1-33 179-9-080 Responses to standards questions A-O A. The proposed project to improve the site is consistent with the policies of the Town's Comprehensive Plan. B. The proposed project complies with all other requirements of this Chapter. C. The proposed residential project has been designed to improve internal pedestrian activities as necessary and applicable to this type of use. D. The existing residence conforms with Chapter 136 Sewage and Sewage Disposal; the proposed project is designed to conform with Chapter 147, the Stormwater Management Local Law and all other applicable laws. E. The proposed project has been designed to be in harmony with the general purpose or intent of this Chapter. F. The proposed project has been designed to be in compliance with principles of good site access, traffic flow, and safety and general welfare of the neighborhood. G. The proposed project has been designed with the intent to provide safe, adequate, and functional off-street parking and loading facilities to the greatest extent feasible. H. The proposed project has been designed to not impact natural, scenic, aesthetic ecological, wildlife, historic, recreational, or open space resources of the Town. The proposed project has been designed to improve internal pedestrian activities as necessary and applicable to this type of use. J. The proposed project has been designed to be in compliance with Chapter 147 as applicable. K. There will be no change in water or wastewater demand for the proposed project; a septic variance is being pursued for holding tanks installations for the parcel. L. The proposed project has been designed to provide an attractive, well-landscaped facility while meeting all functional requirements. M. The project has been designed in effort to meet the needs of emergency service providers adequately. N. The site grading and drainage provisions have been developed with the intent of avoiding flooding and ponding with the exception of areas required for stormwater controls. O. The site has been designed with the intent of conforming to the design standards, landscaping standards, and performance standards of this Chapter. • § 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 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, subdivisions,streets and easements within 500 feet of the property. Such a sketch may be superimposed on a United States S1 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 Si 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. Si D. Name and address of the owner of record,developer,and seal of the engineer,architect or landscape architect. If the Sl applicant is not the record owner,a letter of authorization shall be required from the owner. E. The location and use of all existing and proposed structures within the property,including all dimensions of height and N/A 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 N/A containers shall also be shown. G. The location,height,intensity and bulb type(sodium,incandescent,etc.)of all external lighting fixtures. The direction of N/A illumination and methods to eliminate glare onto adjoining properties must also be shown in compliance with§ 179-6-020. H. The location,height,size,materials and design of all proposed signs. N/A I. The location of all present and proposed utility systems including: 1. Sewage or septic system; 2. Water supply system; 3. Telephone,cable and electrical systems;and Si 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 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 N/A 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 is within the 100-year floodplain,the area will be shown and base flood elevations given. Areas shall be indicated within N/A 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. L. A landscape plan showing all existing natural land features than may influence the design of the proposed use such as rock outcrops,stands of trees,single trees eight or more inches in diameter,forest cover and water sources and all proposed changes to these features,including sizes and types of plants. Water sources include ponds,lakes,wetlands and N/A watercourses,aquifers,floodplains and drainage retention areas. M. 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. N/A 6 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 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; N/A 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. O. For new construction or alterations to any structure,a table containing the following information shall be included: 1. Estimated area of structure to be used for particular purposes such as retain operation,office, Storage,etc.; 2. Estimated maximum number of employees; N/A 3. Maximum seating capacity,where applicable;and 4. Number of parking spaces existing and required for the intended use. P 1. Floor Plans. 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 N/A 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. Si R. Plans for disposal of construction and demolition waste,either on-site or at an approved disposal facility. N/A S. Plans for snow removal,including location(s)of on-site snow storage. N/A T. An Environmental Assessment Form("EAF")as required by the SEQRA regulations,with Part 1 completed by the Applicant 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. N/A U. If an application is for a parcel or parcels on which more than one use is proposed,the applicant may submit a single 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 N/A contiguous parcels shall be considered together. V. 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. 7 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: Randy Gross 2. Tax Map ID 303.16-1-33 (Location:487 Dix Av,east of intersection of Queensbury Ave.&Dix Ave. 3. Zoning Classification4NT SR.t1; f t�c�i±� C✓"r 't�MCC.(l t t7, t 1 4. Reason for Review: u...) ( i,A-f e X PCB \� � c$cv LA r(, ( -sit- . Cx.t-),�le 1��J 5. ZoningSection#: t . ,-L' iIJ {.t,. iC9/N t'�cf " � � (til�?C�l i 6. Pre-Submission Meeting Notes: Provided Out)tanding; Please provide by Deed General Information complete ;f Site Development Data Complete —37 Setback Requirements Complete Additional Project Information Complete FAR addressed t7 Requirements for Site Plan-Standards ✓ _ Checklist items addressed Environmental Form completed 1.2.4 Signature Page completed ---A y \Ac." \- P X V`_X'S -k7 lr�� �z, I/ c.. l +Lh t} f (�"o"ni-e , ( -�L'r )if C , i;(t"or '("C, `L-, s �C5 4 \r,c� t(M 1 teCf J ccui AC 4 S se,,vks A724 - Ault et-n-4 40 e-0ek.,I n 41.)44 r A a kl bc. 4i 51 GHQ c t (.,,..-,i't, ' /kit ti �je_ et. Aity r nt- .tkc1 !C . to C& `C . c,Lsf'ct,[yt, -tit 0)dcr)f( fiz t UI t) i'.-.. k Li!/ ��.0 C, ('V.A.I cit ` c.Lji`� Q a.Jiti r J4 c PL •CG n I CJo t j�fl Jtc&. cin g‘ (..:1 'a JiQL t�cJi(. i ,r C ( ,k)rVCLtV1 ope.4 Cf 40 k- P C C-�i?Sr 'J- Ott l ( %fir ptii.,1 cfxaIr cv ?0,1 !clte c,( Cti.LuiAt /5 - .? �r crk,G[ct rtiC t`s-`U`C? CPP A.'\k -\ Ac\ c, f`1Ci f 1O('Y'1C 1 ( — Ck - G.f-\ f 1 t c:-,.`t ( '— Ott/I (t., e, .1/4.) c.-116 tA_ nt:eel. A. S4 L1,1 'y pp s t - id os Le, k-uu t end , to. a pp lc.c.4 c /�(�� ZC2I%6 Staff Representative: ,r.G..L..3 f C. / 0 ) 1 Applicant/Agent: C _.> Date: 5113 I l 61 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: Designates: Hutchins Engineering As agent regarding: Variance Site Plan Subdivision For Tax Map No.: Section Block Lot Deed Reference: Book Page Date OWNER SIGNATURE: DATE: APPLICANT'S AGENT FORM: Complete the following if the APPLICANT is unable to attend the meeting or wishes to be represented by another party: Owner: Randy Gross Designates: Hutchins Engineering As agent regarding: Variance ✓ Site Plan Subdivision For Tax Map No.: 303.16 Section 1 Block 33 Lot Deed Reference: 3485 Book 184 Page N/A Date OWNER SIGNATURE: DATE: 2.) ENGINEERING FEE DISCLOSURE: 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.) AUTHORIZATION FOR 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. 4.) OTHER PERMIT RESPONSIBILITIES: 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 DISCLOSURE: 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.) AGREEMENT TO PROVIDE DOCUMENTATION REQUIRED: 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 ead and agree to the above. err �C/ ay&,r p &call' S / /9 S atu Ap icant] Print Name [Applicant] a i ed not Vame[Agent] Da a 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. Part 1—Project and Sponsor Information Name of Action or Project: New Beginnings Community Church Inc.-Dix Ave Diner Patio Project Location(describe,and attach a location map): 487 Dix Avenue,east of the intersection of Queensbury Ave.and Dix Ave. Brief Description of Proposed Action: Construct 20'x 45'concrete patio with temporary awning cover for seasonal outdoor dining seating+install 9ft.x 13ft.walk-in cooler. Name of Applicant or Sponsor: Telephone: 518-307-6574 New Beginnings Community Church Inc. E-Mail: dixavediner@gmail.com Address: 487 Dix Avenue City/PO: State: Zip Code: Queensbury NY 12804 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 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 government Agency? NO YES If Yes, list agency(s)name and permit or approval: Town of Queensbury ❑ 3. a. Total acreage of the site of the proposed action? 15.29+/-acres b.Total acreage to be physically disturbed? 0.0154 acres c. Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor? 15.29+/-acres 4. Check all land uses that occur on,are adjoining or near the proposed action: 5. ❑Urban ❑ Rural(non-agriculture) ❑ Industrial m Commercial m Residential(suburban) ❑ Forest ❑ Agriculture D Aquatic ❑ Other(Specify): ❑ Parkland 5. Is the proposed action, NO YES N/A a. A permitted use under the zoning regulations? ❑ ✓❑ ❑ b. Consistent with the adopted comprehensive plan? ❑ ❑✓ ❑ NO YES 6. Is the proposed action consistent with the predominant character of the existing built or natural landscape? El El 7. Is the site of the proposed action located in,or does it adjoin,a state listed Critical Environmental Area? NO YES If Yes, identify: ❑ NO YES 8. a. Will the proposed action result in a substantial increase in traffic above present levels? ❑ El b. Are public transportation services available at or near the site of the proposed action? ri c. Are any pedestrian accommodations or bicycle routes available on or near the site of the proposed � ❑ action? I v 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: El 10. Will the proposed action connect to an existing public/private water supply? NO YES If No,describe method for providing potable water: ❑ ✓❑ 11. Will the proposed action connect to existing wastewater utilities? NO YES If No,describe method for providing wastewater treatment: n ❑ 12. a.Does the project site contain,or is it substantially contiguous to,a building,archaeological site,or district NO YES which is listed on the National or State Register of Historic Places,or that has been determined by the ❑ Commissioner of the NYS Office of Parks,Recreation and Historic Preservation to be eligible for listing on the State Register of Historic Places? b.Is the project site,or any portion of it,located in or adjacent to an area designated as sensitive for ❑ ' 71 archaeological sites on the NY State Historic Preservation Office(SHPO)archaeological site inventory? 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? ❑ Fl 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: Page 2 of 3 • 14. Identify the typical habitat types that occur on,or are likely to be found on the project site. Check all that apply: El Shoreline ❑ Forest ❑Agricultural/grasslands 0 Early mid-successional ❑Wetland ❑ Urban m Suburban 15. Does the site of the proposed action contain any species of animal,or associated habitats,listed by the State or NO YES Federal government as threatened or endangered? ❑ ❑ 16. Is the project site located in the 100-year flood plan? NO YES ❑✓ ❑ 17. Will the proposed action create storm water discharge,either from point or non-point sources? NO YES If Yes, ❑✓ n a. Will storm water discharges flow to adjacent properties? ✓❑ ❑ b. Will storm water discharges be directed to established conveyance systems(runoff and storm drains)? ❑ ✓❑ If Yes,briefly describe: Storm water management completed in 2011 18. Does the proposed action include construction or other activities that would result in the impoundment of water NO YES or other liquids(e.g.,retention pond,waste lagoon,dam)? If Yes,explain the purpose and size of the impoundment: ❑ ❑ 19. Has the site of the proposed action or an adjoining property been the location of an active or closed solid waste NO YES 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 CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE Applicant/sponsor/name: 'l 4..0f / Date: 6 /#e 9 Signature: Title: PRINT FORM Pace 3 of EAF Mapper Summary Report Monday, May 13, 2019 12:51 PM Disclaimer: The EAF Mapper is a screening tool intended to assist project sponsors and reviewing agencies in preparing an environmental assessment form(EAF).Not all questions asked in the EAF are answered by the EAF Mapper.Additional information on any EAF question can be obtained by consulting the EAF Workbooks. Although • " the EAF Mapper provides the most up-to-date digital data available to DEC,you may also need to contact local or other data sources in order to obtain data not provided by the Mapper.Digital data is not a substitute for agency determinations. Ottawa Mc"" f/ • Kingsbury eensbu y, / , Taranto e r i Wit. l E=u€tan Der'. �rcartd!rt�- f '-ESL. ~ .,,k^^. :.+5�S. C.tt.'t0aaand Es = Pittsburgh �- 4 E� ,-ems+fcrrnixis b'�ila#tafiritst. = _ — OI _ [_ `? t _ .,...tcr.arc IreGIS r r cam_ , =;.i_4cs- -s F, ,innate 4t113 r+ ` - - Part 1 /Question 7 [Critical Environmental No Area] Part 1 /Question 12a [National or State No Register of Historic Places or State Eligible Sites] Part 1 /Question 12b [Archeological Sites] Yes Part 1 /Question 13a [Wetlands or Other No Regulated Waterbodies] Part 1 /Question 15 [Threatened or No Endangered Animal] Part 1 /Question 16 [100 Year Flood Plain] Digital mapping data are not available or are incomplete. Refer to EAF Workbook. Part 1 /Question 20 [Remediation Site] Yes Short Environmental Assessment Form - EAF Mapper Summary Report • Agency Use Only[If applicable] Project: Date: Short Environmental Assessment Form 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? 2. Will the proposed action result in a change in the use or intensity of use of land? ❑ ❑ 3. Will the proposed action impair the character or quality of the existing community? ❑ ❑ � I 4. Will the proposed action haw 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? 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: ❑ ❑ a.public/private water supplies? b.public/private wastewater treatment utilities? ❑ n 8. Will the proposed action impair the character or quality of important historic,archaeological, ❑ ❑ architectural or aesthetic resources? 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 ❑ ❑ problems? 11. Will the proposed action create a hazard to environmental resources or human health? ❑ ❑ PRINT FORM Page 1 of 2 Agency Use Only[If applicab .] Project: Date: Short Environmental Assessment Form 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. ❑ Check this box if you have determined,based on the information and analysis above,and any supporting documentation, that the proposed action may result in 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 Date Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Signature of Responsible Officer in Lead Agency Signature of Preparer(if different from Responsible Officer) PRINT FORM Page 2 of 2