Revised Site Plan Application
General Information
Tax Parcel ID Number: ____________________
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Zoning District: ____________________
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Lot size:_____________________
Detailed Description of Project
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[includes current & proposed use
__________________________________________________________________________________________
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Location of project:
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________________________________________________________________________________
Applicant Name: Address:
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Home PhoneCell:
Work PhoneFax
E-Mail:
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Agent’s Name:Address:
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Home PhoneCell:
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Owner’s NameAddress
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Site Plan Review application –Revised October 2016
Town of QueensburyPlanning Office-742 Bay Road, Queensbury, NY 12804
Site Development Data
Area / TypeExisting sq. ft. Proposed Total sq. ft.
Addition sq. ft.
A. Building footprint
B. Detached Garage
C. Accessory Structure(s)
D. Paved, gravel or other hard surfaced area
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E.Porches / Decks
F. Other
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G. Total Non-Permeable [Add A-F]
H. Parcel Area [43,560 sq. ft. / acre]
I. Percentage of Impermeable Area of Site [I=G/H]
Setback Requirements
AreaRequiredExistingProposed
Front [1]
Additional Project Information
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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 New York State Pollutant Discharge Elimination System
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(SPDES) Permit Program ? _______________
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4.Estimated project duration: Start Date __________ End Date __________
5.Estimated total cost of project: _______________
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6.Total area of land disturbancefor 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 DistrictSymbolFloor Area Ratio [FAR]
Waterfront ResidentialWR0.22
Commercial Moderate/ IntensiveCM/ CI0.3
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.Proposed Additional Floor Area___________________________ sq. ft.
D.Proposed Total Floor Area ___________________________ sq. ft.
E.Total Allowable Floor Area ___________________________ (Area x _____) [see above table]
*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 QueensburyPlanning 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 ofall 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 thelocation,
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 l9oading 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.Stormwaterdrainage 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 othersuitable 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 vegetationand
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.
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Site Plan Review application –Revised October 2016
Town of QueensburyPlanning Office-742 Bay Road, Queensbury, NY 12804
§ 179-9-050Checklist-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.
REQUIREMENTSSheet #
A.A vicinity map drawn at the scale that shows the relationship of the proposal to existing community facilities which affect
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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
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
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deem appropriate, on standard 24” x 36” sheets, with continuation on 8 l/2 “x 11” sheets as necessary for written
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.
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D.Name and address of the owner of record, developer, and seal of the engineer, architect or landscape architect. If the
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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
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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,
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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
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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.
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I.The location of all present andproposed utility systems including:
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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
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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
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
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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
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
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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
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
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as any Overlay Districts that apply to the property.
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Site Plan Review application –Revised October 2016
Town of QueensburyPlanning 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
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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 motorvehicle 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:
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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.
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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
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mitigate project impacts.
R.Plans for disposal of construction and demolition waste, either on-site or at an approved disposal facility.
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S.Plans for snow removal, including location(s) of on-site snow storage.
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T.An Environmental Assessment Form (“EAF”) as required by the SEQRA regulations, with Part 1 completed by the Applicant
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shall be submitted as part of the application. If the proposed project requires a special use permit and anEAF 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
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in the Town’s Comprehensive Plan.
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Site Plan Review application –Revised October 2016
Town of QueensburyPlanning Office-742 Bay Road, Queensbury, NY 12804
Town of Queensbury Site PlanPre-Submission Conference Form / Section 179-9-040
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1.Applicant Name: __________________________________________________
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2.Tax Map ID________________Location: _______________________
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3.Zoning Classification__________
ùÍÎÉÈÊÇÙÈÓÍÎÍÖÛÎ×ÅÕÛÊÛÕ×ÅÓÈÔÔ×ÓÕÔÈ×ÄÙ××ØÓÎÕ
1][B,I,][Times New Roman]]__________________________________________________________________________________________________
[[146,2084,544,2136][11][B,I,][Times New Roman]]________________ [[513,2084,2422,2136][11][B,I,][Times New Roman]]__________________________________________________________________________________
[[146,2163,2422,2215][11][B,I,][Times New Roman]]__________________________________________________________________________________________________
[[146,2242,1919,2294][11][B,I,][Times New Roman]]____________________________________________________________________________ [[1888,2242,2423,2294][11][B,I,][Times New Roman]]______________________
[[146,2322,2422,2374][11][B,I,][Times New Roman]]__________________________________________________________________________________________________
[[146,2401,2422,2453][11][B,I,][Times New Roman]]__________________________________________________________________________________________________
[[146,2480,1048,2532][11][B,I,][Times New Roman]]______________________________________ [[1017,2480,2422,2532][11][B,I,][Times New Roman]]____________________________________________________________
[[146,2559,2422,2611][11][B,I,][Times New Roman]]__________________________________________________________________________________________________
[[146,2638,2422,2690][11][B,I,][Times New Roman]]__________________________________________________________________________________________________
Staff Representative: ________________________________
Applicant / Agent:________________________________Date: ___________
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Site Plan Review application –Revised October 2016
Town of QueensburyPlanning Office-742 Bay Road, Queensbury, NY 12804
Signature Page
1.)2.)3.)4.)
This page includes the Authorization to Act as Agent Form: Engineering Fee Disclosure; Authorization for Site Visits;
5.) 6.)
Other Permit Responsibilities; Official Meeting Disclosure and Agreement to provide documentation required.
O’AF:
WNERSGENT ORM
OWNER
Complete the following if the of the property is not the same as the applicant
Owner: ____________________________________
Designates:____________________________________
As agent regarding:_____ Variance_____ Site Plan_____ Subdivision
For Tax Map No.:_____ Section_____ Block_____ Lot
Deed Reference:_____ Book_____ Page_____ Date
OWNER SIGNATUREDATE
: ___________________________________: _______________
A’AF
:
PPLICANTSGENT ORM
ifAPPLICANT
Complete the following the is unable to attend the meeting or wishes to be represented by another party:
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Owner: ____________________________________
÷ÈÔÛÎôÛÐÐêÇÙÓÎÉÑÓôÛÐÐûÊÙÔÓÈ×ÙÈÇÊ×
Designates:____________________________________
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As agent regarding:_____ Variance_____ Site Plan_____ Subdivision
For Tax Map No.:_____ Section_____ Block_____ Lot
Deed Reference:_____ Book_____ Page_____ Date
OWNER SIGNATUREDATE
: ___________________________________: _______________
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 propertiesfor 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 toissuance 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 zoningregulations. 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.
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____________________________ _____________________________________________
Signature [Applicant]Print Name [Applicant]Date signed
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_________________________________________________________________________
Signature [Agent]Print Name [Agent]Date signed
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Site Plan Review application –Revised October 2016
Town of QueensburyPlanning Office-742 Bay Road, Queensbury, NY 12804
[[729,165,1819,240][16][B,I,][Times New Roman]]Short Environmental Assessment Form
[[934,244,1134,309][14][B,I,][Times New Roman]]Part 1 [[1098,244,1148,309][14][B,I,][Times New Roman]]- [[1131,244,1632,309][14][B,I,][Times New Roman]]Project Information
Instructions for Completing
Responses become part of the
Part 1 – Project Information. The applicant or project sponsor is responsiblefor the completion of Part 1.
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:
î×ÅõÛÊÛÕ×ùÍÎÉÈÊÇÙÈÓÍÎ
Project Location (describe, and attach a location map):
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Brief Description of Proposed Action:
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ÙÛÊÕÛÊÛÕ×ÈÍÚ×ÚÇÓÐÈÍÎÌÊÍÌ×ÊÈÃÍÖÈÔ×ÍÅÎ×Ê
Name of Applicant or Sponsor:
Telephone:
E-Mail:
úÓÐÐìÍÕÍÎÍÅÉÑÓ
ÚÓÐÐüÛØÑÖ×ÎÙ×ÙÍÏ
Address:
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City/PO:State:Zip Code:
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1.Does the proposed action only involve the legislative adoption of a plan, local law, ordinance,
NOYES
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?
NOYES
If Yes, list agency(s) name and permit or approval:
èÍÅÎÍÖëÇ××ÎÉÚÇÊÃâÍÎÓÎÕæÛÊÓÛÎÙ×èÍÅÎÍÖëÇ××ÎÉÚÇÊÃìÐÛÎÎÓÎÕ
èÍÅÎÍÖëÇ××ÎÉÚÇÊÃúÇÓÐØÓÎÕì×ÊÏÓÈ
3.a. Total acreage of the site of the proposed action? __________ acres
b.Total acreage to be physically disturbed? __________ acres
c.Total acreage (project siteand any contiguous properties) owned
or controlled by the applicant or project sponsor? __________ acres
Check all land uses that occur on,adjoining near the proposed actio
Rural(non-agriculture)ndustrialCommercialResidential(suburban)
ForestAgriculture
Parkland
Page 1 of 3
5.Is the proposed action,NOYESN/A
a.A permitted use under the zoning regulations?
b.Consistent with the adopted comprehensive plan?
NOYES
6.Is the proposed action consistent with the predominant character of the existing built or natural landscape?
7.Is the site of the proposed action located in, or does it adjoin, a state listed Critical Environmental Area?
NOYES
îÛÏ×ðÛÑ×õ×ÍÊÕ×ê×ÛÉÍÎìÊÍÈ×ÙÈÈÔ×Ê×ÉÍÇÊÙ×ÉÍÖÈÔ×ÌÛÊÑûÕ×ÎÙÃðÛÑ×õ×ÍÊÕ×ìÛÊÑùÍÏÏÓÉÉÓÍÎøÛÈ×
If Yes, identify: ________________________________________________________________________________
NOYES
a.Will the proposed action result in a substantial increasein traffic above present levels?
Are public transportationservices available at or near the site of the proposed action?
Are any pedestrian accommodations or bicycle routesavailable on or nearsite of the proposed
action?
9.Does the proposed action meet or exceed the state energy code requirements?
NOYES
If the proposed action will exceed requirements, describe design features and technologies:
_____________________________________________________________________________________________
èÔ×Î×ÅÉÈÊÇÙÈÇÊ×ÅÓÐÐÎÍÈÚ×Ô×ÛÈ×ØÛÎØÈÔ×Ê×ÖÍÊ×ÓÉÎÍÈÊ×ËÇÓÊ×ØÈÍÏ××ÈÈÔ××Î×ÊÕÃÙÍØ×Ê×ËÇÓÊ×Ï×ÎÈÉ
_____________________________________________________________________________________________
10.Will the proposed action connect toan existingpublic/privatewater supply?
NOYES
If No, describe method for providing potable: _________________________________________
îÍÊÇÎÎÓÎÕÅÛÈ×ÊÓÉÎ×Ù×ÉÉÛÊÃÓÎÈÔ×ÕÛÊÛÕ×
_____________________________________________________________________________________________
11.Will the proposed action connect to existing wastewater utilities?
NOYES
If No, describe method for providing wastewater treatment: ______________________________________
îÍÊÇÎÎÓÎÕÅÛÈ×ÊÓÉÎ××Ø×ØÓÎÈÔ×ÕÛÊÛÕ×ÈÔ×Ê×ÖÍÊ×ÎÍÉ×Å×ÊÓÉÊ×ËÇÓÊ×Ø
_____________________________________________________________________________________________
NOYES
. Does any portion of thesite of the proposed action, orlands adjoining the proposed action, contain
NOYES
wetlands or otherwaterbodies regulated byafederal, state or local agency?
Would the proposed actionphysically alter, or encroach into, any existing wetland orwaterbody?
If Yes, identify the wetland or waterbody and extent of alterations in square feet or acres: _____________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Page 2 of 3
Identify the typicalhabitat types that occur on, or are likelyto be found on the project site. Check all that apply:
ShorelineForest
Agricultural/grasslands Early mid-successional
WetlandUrban Suburban
15.Does the site of the proposed action contain any species of animal, or associated habitats, listed by the State or
NOYES
Federal government as threatened or endangered?
îÍÊÈÔ×ÊÎðÍÎÕ×ÛÊ×ØúÛÈ
16.Is the project site located in theloodplan?
NOYES
NOYES
17.Will the proposed action create storm water discharge, either from point or non-point sources?
If Yes,
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:
_____________________________________________________________________________________________
êÍÍÖ×ÛÆ×ÈÊ×ÎÙÔ×ÉÅÓÐÐÚ×ÇÈÓÐÓÂ×ØÈÍÙÍÎÈÊÍÐÊÍÍÖÊÇÎÍÖÖ
_____________________________________________________________________________________________
18.Does the proposed action include construction or other activities thatresult in the impoundment ofwater
NOYES
other liquids(e.g. retention pond,waste lagoon, dam)?
or
If Yes, explainpurpose and size
____________________________________________________________________________________________
_
19.Has the site of the proposed action or an adjoining property been the location of an active or closed solid waste
NOYES
management facility?
If Yes, describe: _______________________________________________________________________________
_____________________________________________________________________________________________
20.Has thesite of the proposed action or an adjoining property beensubject of remediation (ongoing
NOYES
for hazardouswaste?
completed)
If Yes, describe: _______________________________________________________________________________
_____________________________________________________________________________________________
I THAT THEINFORMATION PROVIDED ABOVE IS TRUEAND ACCURATE TO THE BEST OF
MYKNOWLEDGE
Applicant/sponsorname:______________________ Date:_______________________________________________
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÷ÈÔÛÎìôÛÐÐ
Signature: _____________________________________________________
ûÊÙÔÓÈ×ÙÈàûÕ×ÎÈÖÍÊÈÔ×ûÌÌÐÓÙÛÎÈ
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[[2414,3217,2464,3255][8][B,I,][Times New Roman]]1
Part 2
Answer all ofthefollowingquestionsin Part 2 using theinformation contained in Part 1 and other materialssubmitted by
theprojectsponsoror otherwise availableto the reviewer. When answeringthequestionsthereviewershould be guided by
theconc
No, or Moderate
small to large
impact impact
may may
occuroccur
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?
4.Will the proposed action have an impact on the environmental characteristics that caused the
establishmentof 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?
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 proposedaction create a hazard to environmental resources or human health?
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Foreveryquestion in Part 2 that was
particularelementoftheproposed action may orwillnotresultin a significantadverseenvironmentalimpact, please
completePart3. Part 3 should, in sufficient detail,identifytheimpact, including anymeasuresor design elements that
havebeen included by theprojectsponsorto avoid or reduceimpacts. Part 3 should also explain howthelead agency
determined that theimpactmayorwillnotbesignificant. Each potential impactshould be assessed considering itssetting,
probabilityofoccurring, duration, irreversibility, geographic scopeandmagnitude. Also consider thepotentialforshort-
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 notresult in any significant adverse environmental impacts.
________________________________________________________________________________________________
Name of Lead AgencyDate
________________________________________________________________________________________________
Print or Type Name of Responsible Officer in Lead AgencyTitle of Responsible Officer
________________________________________________________________________________________________
Signature of Responsible Officer in Lead AgencySignature of Preparer (if different from Responsible Officer)
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