Site Plan Review application • Revised May 2009
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)761-8220 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:
Please submit 1 original & 14 copies of the completed application package to include:
• Completed Application: pages 1-11 completed, signed &dated
• Pre-Submission Meeting Notes: signed by staff
• for Site Plan Approval
• New: Checklist& Plot Plan
• Fee 0 - 10,000 sf = $100
10,001- 30,000 sf = $250
30,001- 100,000 sf= $500
100,000 + sf = $1000
ZONING STAFF & CONTACT INFORMATION
Craig Brown, Zoning Administrator craigbCc gueensbury net
Keith Oborne, Land Use Planner keitho(aoueensbury net
Pam Whiting, Office Specialist 518-761-8220 gamw(a)gueensbury net
Visit our website at www.gueensbury.net for further information and forms
Town of Queensbury Planning Office- 742 Bay Road•Queensbury, NY 12804• 518-761-8220 1
Revised May 2009
General Information
Tax Parcel ID Number:
Zoning District: f,QC/ffl /AiT�ys/(/�
Detailed Description of Project [include current&proposed use]:
86! lg � 40�/f7///i6 Dili/�ftTf pF LiiolBysBLI/Lpi T�
4fe6y2Z. /5` e4 TA// tf �y�T/ef/AF T/fg F/�PsT
rznmR/S e,y yX BY T//� HOC
Location of project:
Tel ST/frTf"BOI/T6 �
Applicant Name; S/n/PXL ftD1O/ �LG Address:
y '
Home Phone Cell.
Work Phone Fax
E-Mail:
„s.
Agent's Name: /fuTL,yyy��jfpj//yc��'/y
w
Home Phone Cell.
Work Phone 030
7 Fax
E-mail- TF}uTC//i/vr�
lfltTL7f//!}' /ysE'
Owner's Name /C/V'! � Address OX
Home Phone Cell
Work Phone Fax
E-mail
Town of Queensbury Planning Office- 742 Bay Road-Queensbury.NY 12804 518-761-8220 2
Revised May 2009
Site Development Data
Area/Type Existing sq.ft. Proposed Total sq. ft.
Additions . ft.
A. Building footprint 10 r$J( [O, !SS
B. aka pAVlbfanl 5-7-70
SZ�i'D
C. Accessory Structure(s)
D. Paved, gravel or other hard surfaced area A6670 /6V
E. Porches/ Decks 'TO
F. Other
G. Total Non-Permeable [Add A-F]
H. Parcel Area [43,560 sq. ft./acre] t s��(av sF �56 066
I. Percentage of Impermeable Area of Site [I=G/H] 3f v Z '34.Sz9e
Setback Requirements
Area Required Existing Proposed
�t
Front[1] 7$ —7Z,77 ' -72. 77
Front(2]
Shoreline
Side Yard [1] t
A/04M 3U 20I.749 2671•70
Side Yard [2] r SU suer r r
SauTN 2U 21 .7� 2l•?8
Rear Yard [1] ZS r 2�5. 5`S r 2 ✓ SS r
Rear Yard [2]
Travel Corridor
Height[max] -40 �D r
Permeability 3d h �D /g? O•
No. of parking spaces -W
Town of Queensbury Planning Office 742 Bay Road•Queensbury,NY 12804. 518-761-8220 3
Revised May 2009
Additional Project Information
1. Will the proposal require a Septic Variance from the Town Board of Health?
2. If the parcel has previous approvals, list application number(s):
3. Does this project require coverage under the NYS DEC Stormwater Pollution Prevention
Program? ND
4. Estimated project duration: Start Date End Date
5. Estimated total cost of project:
6. Total area of land disturbance for project: �^
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 CM 0.3
Commercial Intensive Cl 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.
Parcel Area s .ft.
Existing Floor Area / s .ft. see above definition
Proposed Additional Floor Area s .ft.
Proposed Total Floor Area -ZWIK s .ft.
Total Allowable Floor Area 1441 C7.0 Area x see above table
Town of Queensbury Planning Office, 742 Bay Road-Queensbury,NY 12804• 518-761-8220 4
Revised May 2009
§ 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 or 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 Stormwa[er Management Local Law, end
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 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 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 prevision 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 pending,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.
Town of Queensbury Planning Office- 742 Bay Road-Queensbury,NY 12804- 518-761-8220 5
Application questions A-O responses:
A) The applicant is proposing to revitalize this site with allowing the Knights of
Columbus Council 194 to remain in the 1st floor section of the front portion of the main
building and with the applicant using the original banquet hall portion for a custom
showroom and is planning to do so in a way that ultimate significantly reduces internal
site activity by eliminating the current banquet facility and its related requirements for
parking. Applicant also intends to enhance the property, especially at the street by
planting additional trees, as the Town requires in this corridor,approximately every 35'in
order to achieve a more pleasant community appearance. The building itself will remain
with its current Adirondack oriented color schemes and materials including cedar siding
and brick canopied entrance. No exterior changes to the buildings are planned. No
grading of the site is planned and no additional entrances to the parcel are planned.
B) Given the only change is that of the primary use of the building and the change in
ownership The project appears to be in compliance and the applicant is requesting
waivers for grading(since there is none planned), fighting(since the current lighting
appears sufficient, especially with the primary use being changed from evening/nighttime
banquet hall to daytime oriented showroom), and stormwater(as no changes to the site
are being made and the current system appears to be adequate).
C) The site plan and the arrangement of parking encourage internal pedestrian activity.
In fact,the required number of parking spaces,as per the code, appear to be significantly
greater than the needs of the applicant who generally needs 5 or 6 spaces maximum at
one time for the showroom activity.
D) In the past,the site was granted waivers by the Town Board for hook-up to the sewer
system along route 9 and the applicant,understands that the current owner is in the
process of applying for an additional 2 year waiver before mandatory hook-up which
appears to be consistent with recent Town Board approvals in the area. The applicant
intends to connect to the Town sewer as part of this application.
E) The character and size of this project appears consistent with the surrounding
properties and the project has extensive areas of openness. The current intensive use of
the property, especially at night and on weekends is expected to be significantly reduced
with the change of use. If anything,the burden on services should be lower.
F) Access to the property remains the same and is expected to decrease with the change
of use. There are no planned changes to the current access points. The application
appears to be generally consistent with Town requirements.
G) Plenty of off-street parking is allowed for on site. Should development of the
adjacent parcel to the north require an interconnect in the future,the applicant anticipates
working with the Town and the owner of that parcel,provided the liabilities of
interconnecting the two parcels are within reason. With the size of the applicants parcel,
there are several opportunities to place a potential interconnect, should the need arise.
I-I)The applicant believes the change in primary use will have an overall positive impact.
With no changes to the site planned,there should be no impact to environmental
resources, etc.
1) The applicant believes that the parking and proposed existing layout are sufficient to
meet its needs and if anything,too much parking is planned,as per Code.
.1) No changes to grading or the building are planned and the current storm water controls
appear to be managing the stormwater. There are several drywells on site and primary
portion of the showroom building has roof gutters and drains to manage the water flow
from the main roof surface.
K) The existing facilities are more than adequate for the intended use as the intended use
will significant reduce the load on the existing septic system(if it were to remain in use)
and the Town supplies water,which will again be significantly reduced in use.
L) The proposed addition of trees along route 9 and the maintenance of the existing
maples and other mature trees and shrubs on site seem adequate for the proposed use.
M) Preliminary discussions with Mike Palmer have indicated there are no issues with the
ability to access the property but the applicant fully intends to implement any suggestions
that may arise.
N) There are no know concerns in this area and non are expected to be created given no
change is planned for the site.
O) Other than the requested waivers,the applicant believes the design standards are in
keeping with the intent of the Code.
' § 179-9-050 Application for Site Plan Review Revised May 2009
Application for site plan approval shall be made to the Planning Board using forms supplied by the Board.Application materials
and the site plan shall include sufficient information for the Board to make its findings under§179-9-070 and 179-9-080 below.
In determining the content of the site plan and supporting documentation,the Planning Board may waive certain requirements if
the Planning Board deems such requirements or information unnecessary for the type of project proposed. Any such waiver
shall be made in writing, and shall contain statements of the reasons why the waived information requirements are not
necessary for an informed review under the circumstances. The Planning Board may grant such waivers on its own initiative or
at the written request of an applicant.Such request shall set forth the specific requirements that are requested to be waived and
the reasons for the requested waiver. Absent any waiver or waivers, an application for Site Plan Review shall include the
following:
Shown
REQUIREMENTS on 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, S 17 fZ
streets,and easements within 500 feet of the property. Such a sketch may be superimposed on a United Stales 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 SI Sz
deem appropriate,on standard 24"x 36"sheets,with continuation on 6Yi'x 11"sheets as necessary for written information. i
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. 51 5 Z
D Name and address of the owner of record,developer,and seal of the engineer,architect,or landscape architect. If the
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 floor SI
area,all exterior antrances,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, s� 5 Z
sidewalks, ramps,curbs, paths,landscaping,walls,and fences. Location,type,and screening details for all waste disposal /
containers shall also be shown.
G The location, height. Intensity, and bulb type (sodium,incandescent, etc.)of all external lighting fixtures. The direction of
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.
I The location of all present and proposed utility systems including:
1. Sewage or septic system; fz
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 sudace 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 6!!Mfl
activities (excluding agricultural activities) on the site that results in land disturbance of 1-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 1-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 Stales Coastal and Geodetic Bench Mark. If any portion of the parcel Is
within the 100-year floodplain,the area will be shown, and base good elevations given. Areas shall be indicated within the
proposed site and within 50 feet of this 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 that 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 SL
changes to these features including sizes and types of plants. Water sources include ponds, lakes, wetlands and
watercourses,aquifers,floodpiains,and drainage retention areas.
Town of Queensbury Planning Office- 742 Bay Road-Queensbury,NY 12804• 518-761-8220 6
Revised Ma' 2009
M Land Usa DisMct boundaries within 500 feet of the site's perimeter shall be drawn and itlentified on the site plan,as well as
any Overlay Districts that apply to the property. G
N Traffic Bow patterns within the site,entrances and exits,and 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 52
for those in heavy traffic areas,which shill 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.
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 retail operation,office,storage,etc.; 52
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 Elevations at a scale of one-quarter inch equals one foot(1 IN'=1 foot)for all exterior facades of the proposed structure(s) I>M6rOS
and/or alterations to or expansions of existing facades,showing design features and indicating the type and color of materials 6AAa
to be used.
Q Soil logs,water supply well and percolation test results,and storm runoff calculations,as needed to determine and mitigate W LAN
project Impacts, .01 sr
R Plans for disposal of construction and demolition waste,either on-site or at an approved disposal facility. O FtrSLr
S Plans for snow removal,including location(s)of on-sits snow storage. 5z
T An Environmental Assessment Form('EAF"),as required by the SEQRA regulations,with Part i 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.
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
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 1`1
in the Tom's Comprehensive Plan.
Town of Queensbury Planning Office- 742 Bay Road-Queensbury,NY 12804- 518-761-8220 7
' Pre-Submission Conference Form f179-4-0401 Revised May 2009
1. Tax Map ID OW.13
2. Zoning Classification
3. Reason for Review: iN U
4. Zoning Section#: X/ es
Pre-Submission Meeting Notes;Outstanding Its To Be Addressed Include:
Deed Yes _No
General Information complete Yes No
Site Development Data Complete9- Yes
Yes No
Setback Requirements Complete o
Additional Project Information Complete Yes No
FAR Worksheet complete —/Yes No
Standards addressed �Yes No
Checklist Items addressed {/�_Yes �,{..�No
Environmental Form completed Yes NITS No
Signature Page completed _Yes _1_o" No
MPG�.c r9 /GAT/Ca�U
Staff Representati
Applicant/Agent:
Date:
Town of Queensbury Planning Office- 742 Bay Road•Queensbury.NY 12804- 518-761-8220 8
Revised May 2009
taT51(I 1I851—Text tP
PROJECT I.O.NUMBER 817.20 SEO R
Appendix C
State Environmental Quality Review
SHORT ENVIRONMENTAL ASSESSMENT FORM
For UNLISTED ACTIONS Only
PART I—PROJECT INFORMATION(To be completed by Applicant or Project sponsor)
1. APPLICANTT11SOfl 2. PROJECT NAME
XL 1tO6ale
0. PROJECT LOCATION:
Municipality Count
A. PRECISE LOCATION(Street address and road intersections.R.Inent landmaree,atc..or provide map)
`f8'f sr/mE,gor^rEq
S. IS PROPOSED ACTION:
❑New ❑EApsnsion Motli11ca11pUaltenllan
S. DESCRIBE PROJECT BRIEFLY:
e-;' f7VYtT6 EX/ST/�l/�F I-Ai/6NTf®FloGumBr/s Bu/�pi�6
'ry 5!_ROW7rr R��/G SNot�viQp�nj
7. AMOUNT OF LAND AFFECTED'.
Initially acres Ultirnuel ��
ar
S. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS?
Myer; ON* If No,descno.bnelly
S. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT?
1:1Residen101 ❑Industrial �Cpmmercbl ❑Agrkolture ❑P*,wFore.VOpm a pace ❑other
Describe:
10. DOES ACTION INVOLVE A PERMIT APPROVAL,OR FUNDING,NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY(FEDERAL.
STATE OR LOCAL)?
❑Yea RNo If yea,list agencyng no permlVapprovaM
it. WES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL?
❑ IWYea No II yes,list agency name and permlUepproval
12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMITIAPPROVAL REWIRE MODIFICATION?
❑Yes No
I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
A
Appllcantleponmr name: ✓` r, C N ✓ 3
Da a:
slgnaWe:
If the action Is In the Coastal A a, and you are a state agency, complete the
Coastal Assessment Form efore proceeding with this assessment
OVER
1
Town of Queensbury Planning Office-742 Bay Road Queensbury,NY 12804 518-761-8220 9
Revised May 2009
• PART II—ENVIRONMENTAL ASSESSMENT(To be completed by Agency)
A. DOEa ACTION EXCEED ANY TYPE I THRESHOLD IN 8 NYCRR PART Si?.a? If yes,coordinate m&review process and ua.the FULL EAF.
❑Yea ❑No
B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR,PART 817.87 It No,a negative Ofainvanan
may bo suPersedetl by another involved agency.
❑Yes ❑NO
C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING:(Answers may be handwritten,If l.glble)
CL Exiating ell quality, Surface Or groundwater quality or quenpty,plea 1e1e10. wilding Inif to patterns Wild wart.produollon or disposal.
pohntlal for asides,drainage or flooding problems?Explain briefly:
CZ Aesthetic agricultural.archaeological,hlslorlG,or other natural or cultural latitudinal of Community Or neighborhood character?Explain brlany:
Cl Vegetation or fauna,fish,shellfish or wildlife species,algnRteanl habitats,or Imiatened or endangered spaotes?Explain briefly:
C6.A GOTTunity'.existing of..Or goal.as officially i dopled,or a cbang.In use Or Intensity of Use of land or other natural resources?Explain briefly
C5.Growth,subsequent devalcomeni bl related Witryleea likely to Oe Induced by Me prop...d action?Expleln onally.
CO. Long term,shoe term,cumulative,or other%pacts not identified In CI'05?Explain briefly.
C7. Other Impacts pncluding than...In use of either quantity or type of energy)?Explain briefly.
D.WILL THE PRDJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CEA?
❑vs. ❑No
E.IS THERE,OR IS THERE LIKELY TO BE,CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS?
❑Yee ❑No if Yes,explain briefly
PART III—DETERMINATION OF SIGNIFICANCE(To be completed by Agency)
INSTRUCTIONS: For each adverse effect Identified above,determine whether It is substantial,large,Important or otherwise significant.
Each effect should be assessed In connection with its(a) Setting(i.e.urban or rural); (b) probability of attuning;(c)duration;(it)
Inerveratbility;(9)geographic Scope;and If)magnitude.If necessary,add attachments Or reference supporting materiels.Ensure that
explanations contain sufficient detail to show that all relevant adverse Impacts have been identified and adequately addressed.If
question O of Pan It was checked yes,the determination and significance must evaluate the potential Impact of rho proposed Option
on the environmental characteristics of the CEA.
❑ Check this box if you have Identified one or more potentially large or significant adverse Impacts which MAY
occur.Then proceed directly to the FULL EAF and/or prepare a positive declaration.
❑ Check this box If you have determined, based on the information and analysls above and any supporting
documentation, that the proposed action WILL NOT result In any significant adverse environmental Impacts
AND provide on attachments as necessary, the reasons supporting this determination:
Name of ea Ayenq
Pont or TYPE Hama of Respomi a Olficer,n Lee pncy Title Of mvansr e Officer
1eaxlure Of ItMomfile Cisco in Lead Agency Swindle.1 Pnipar.,(11 , event rpm responx o rter
Dale
2
Town of Queensbury Planning Office- 742 Bay Road •Queensbury,NY 12804- 518-761-8220 10
Revised May 2009
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�>] ���ly� r�jdw h (�1 ,c�3t���lCouxa�
As agent regarding: Variance_ Site Plan_Subdivision
For Tax Map No.: .n^7-C_i_a_ Section _,L-Block Lot
Deed et ce: Bo Page _ 1�ft�Date
OWNER SIGNATURE:: 6
APPLICANT's AGENT FORM:
Complete the following if the APPLICANT is unable to attend the meeting or wishes to be represented by another
party: 1�
Owner: tl to G !-' (_n�_$NMS � as /
Designates:�,�]'�.erv,., tJ�Jt.�.tinV 1"1C�lIIyt1-,. �1��' `�
As agent regarding: Variance>_Site Plan Subdivision
For Tax Map No.: ag[� Section __�_Block Lot
Deed R ence: Bo ?�a�Page S it
OWNER SIGNATURE G o O
i
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.
3.1 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
Ferti,ticate of occupancyy����
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Signature [Applicant] ( Print Name[Applicant] Date signed
[SSiignature [Agent] Print Name [Agent] Date si�In d
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To441iQueensbury Planning Office- 742 Bay Road Queensbury,NY 12804. 518-761- 220 11
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COUNCIL 194 `:;��