Application J
8/20/02 Site Plan Review
General Information
Application No. (Office Use Only)
Project Location: L-,&r-A. T IffL sTrzmeT
Tax Map ID: Soz. & - I -
Zone Classification: W14 UWA-f 60MMG2G1AL - MOO eATE
Compliance with Zoning Ordinance Section:
Detailed Description of Project:
(include current& proposed use): Col-rbTtw NEW /Surd REP6I2
Y.7UIl�Dlw. - 6 A WAP-ffWoosr; 1-1EW PA1yrzAAI<NT
?Aay-Lt J6 A -SITE (:2XVe,1-0FnAV,1 4 -
Modification to existing Site Plan, Yes: No: X
(If so,indicate Site Plan No.& approval date)
Square Footage of proposed structure: G+3GD sF
Applicant: WAeP$r-J 71er
Address: 4 1 EIS!I L atJ D .&V E
QyEEi./SP�y2� N'( lZ&�¢
Home Phone:
Work Phone/Fax: 19 L - O 316,
Applicant's Agent: ,at nEs AA iL me M IuEP- /AS5a obTes
Address: 1491 1-14VILdND R.odD
QUFEENSfbe�2`( t-I`( IZ8O4
Home Phone: -lg71 - 4.4 S$
Work Phone/ Fax: 1yz - 85"( 1
Property Owner: 2ruaoJo rxI IG¢k¢,2Ncvt6i J1=
Address: T A r- Ptopsjvri mn. l tie
I S r F5t,00/E 190t vE
Home Phone: QL)mEN.6$vex Nr l Z$o¢
Work Phone/ Fax:
Directions to Site: _
t_aPAY�rrE ST: �sT � l LAN ST. _ _-
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8/20/02 Site Plan Review
Site Development Data
Area/Type Existing sq. ft. Proposed Addition Total sq. ft.
sq. ft.
A. Building Footprint
G, 3i3 G,3Go IZ,G13
B. Detached Garage
C. Accessory Structure(s)
D. Paved, gravel or other s
hard surfaced areas Soo `f i `I 5
E. Porches/Decks _
F. Other _
Total Non-Permeable
Sum A through F) 1 7 Z4186¢ $8t 6 3 I
Parcel Area S4 33� q-31 G9 9 8 03-7
Percent Non-Permeable
Total Non-Permeable/Parcel Area
Setback Requirements
Required Existing Proposed
Front (1) Sa S`[. 2 S3, o
Front(2) _ _ —
Shoreline
Side Yard(1) ZS 37 cl 3T.9
Side Yard(2) Zs Z8• $•O.O
Rear Yard(1) Z S 140. 7G $Z•48
Rear Yard(2)
Buffer/Travel Corridor —. _
i
Height 40
Permeability 300 41.5% 40-Z%
Sign Setback Ic IS is-
No. of Parking Spaces 713 4 1 5"n 45 2 3 et o
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8/20/02 Site Plan Review
Checklist—please prepare a map depicting existing and proposed conditions. Failure to complete the following
checklist or include all required information may result in a determination of incompleteness and a delay in the
processing of your application
PR NA wR Address Each Item
GENERAL
A.Title,name, address of applicant&person responsible for preparation of drawing
B.North arrow,Tax Map ID, date prepared and scale(minimum 1 in. =40 ft.)
C.Boundaries of the property plotted to scale,zoning boundary
D. Location of principal structures, accessory structures with exterior dimensions
E. Location of site improvements incl. outdoor storage areas, driveways (existing & proposed) parking
areas, etc.
F. Setbacks for all structures and improvements
G. Elevations of proposed structures
WATER& SEWER
A. Location of on-site sewage disposal facilities, design details, construction details, flow rates, and
number of bedrooms proposed
B. Location of water supply(i.e., well) and septic on adjoining lots with separation distances to existing
or proposed on-site water supply and septic
✓ C. Separation distances for proposed sewage disposal system to well and waterbodies
D. Location and description of existing public or private water supply (well, lake, etc.). Method of
✓ securing public or private water, location, design and construction of water supply including daily water
usage
v E. Percolation test location and results
PARKING/PERMEABLE AREAS
✓ A. Number of spaces required for project including calculations and justification
B. Number of existing parking spaces,number to be removed,number to maintain and type of surfacing
material e. ., ave1,paved)
C.Provision for pedestrian and handicap access and parking
D. Location and design details of ingress,egress,loading areas and cutting
E. Location and character of green areas(existing and proposed), modification to green area,buffer zone
to remain undisturbed
v F. Lighting, location and design of all existing or proposed outdoor lighting
ADDITIONAL SITE DEVELOPMENT AND MISCELLANEOUS
v A. Location of on-site&adjacent watercourses, streams,rivers,lake and wetlands
u B. Location of proposed&existing: utility/energy distribution systems(gas, electric,solar,telephone)
C. Location, design and construction of all existing and proposed site improvements including: drains,
v culverts,retaining walls, fences, fire&emergency zones and hydrants
D. Location and amount/portion of building area proposed for office,manufacturing,retail sales or other
commercial activities
V E. Signage: Location, size,type,design and setback
F. Waiver Request: provide letter with application requesting any waivers
G. Commercial / Industrial. Development requires submission of a Landscaping Plan, Stormwater
L Management Plan,Grading Plan and a Lighting Plan
Y H. The Bd.may request other elements as considered necessary.
v I. Identify any Federal, State or County permits required for the project.
I Please submit record of application for approval status of all necessary pern its required from Federal,
State and Coun officials.
Legend: PR— Provided; NA—Nqt Applicable; WR—Waiver Requested n
8/20/02 Site Plan Review
Signature Page
This Page includes the Authorization to Act as Agent Form, Engineering Fee Disclosure, Other Permit
Responsibilities and Agreement to provide documentation required.
Complete the following if the OWNER of the property is not the same as the applicant
Owner's Agent Form etc-WARp -GCWr_Q/M0_2µoRN JP
-
Owner: T-1 2 Peofine-n F-s
Designates: R06E2T IG9Gt4D44
As agent regarding Variance ( Site Plan Subdivision
For Tax Map No.: 30Z_(e Section I Block Zp. 1 Lot
Deed Reference: Book Page _Date
SIGNATURE: (Owner) ¢ lk a3 (Date)
Complete the following if the APPLICANT is unable to attend the meeting or wishes to be represented
by another party:
Applicant's Agent Form
Arrucpw weer: Pyrwar Ve
Designates: 3AM" MIUAW_
As agent regarding: _Variance Site Plan Subdivision
For Tax Map No.: 30z,L Section l Block Zp_I Lot
! v SIGNATURE: � ' 14j* — t(Owner)_q o�(Date)
�
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.
Please Note: 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.
Official Meeting Minutes Disclosure: It is the practice of the Community Development Dept. to have a
designated stenographer tape record the proceedings of meetings resulting from application, and that
minutes transcribed from those tapes constitute the official record of all proceedings. If there is a
discrepancy between such record and the handwritten minutes taken by the designated stenographer, the
handwritten minutes shall be deemed the official record.
1, the undersigned, have thoroughly read and understand the instructions for submission, agree to
the submission requirements and completed the checklist.
SIGNATURE OF APPLICANT: V`t -Date f.
SIGNATURE OF AGENT: -Date 4 to ,
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8/20/02 Site Plan Review
PRE—APPLICATION CONFERENCE FORM
Please note that the Town of Queensbury Zoning and Subdivision of Land Codes contain many requirements
that potentially affect a project.
Effective immediately all applicants must meet with staff for a Pre-Application Conference prior to completing
your application and submitting it to the Community Development Department for processing. Please call
(518) 761-8220 to make an appointment. The intent of this requirement is to assist applicants in meeting the
minimum submission requirements, and to address any other issues or recommendations identified by staff.
Applications must be complete to be placed on an agenda.
When you meet with staff, we will initial and date this form. When you submit your application, please attach
this completed form. The completed form is considered part of your application. Thank you for your
cooperation. Our goal is to help you!
Applicant Name WA"r-u TLIL
Tax Map No.
Zoning Classification
APA, CEA
Zoning Ordinance Compliance Section:
DESCRIPTION OF PROJECT:
PRE-APPLICATION MEETING NOTES:
Con.p(1& a nna c n
' 6,3 Date(s) of Pre-Application Conference
Applicant Initials
Staff Member Initials
Nothing stated in this meeting is to be construed as an approval or disapproval. The sole intent of the pre-
application meeting is to address submission requirements and to identify potential concerns. All content of
submissions is the responsibility of he applicant or authorized designee.
8/20/02 Site Plan Review
14-164 011961—Text 12
PROJECT I.D.NUMBER 617.2D SEOR
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. APPLICANT/SPONSOR 2. PROJECT NAME
waV-a-M1,4 12V aeeEr-1 Tlk.V
J. PROJECT LOCATION: A
Municipality U Count ,O K KE.N
4. PRECISE LOCATION(Street acoress and road intersections,prominent landmarks,etc.,or provide map)
e i-re. STe>=E7- To EXISTI N,:�
Wo2 ¢E1�1 Tt2E
5. IS PROPOSED ACTION:
❑New IffETpan9len ❑MOdifcalion/altanlion
6. DESCRIBE PROJECT BRIEFLY:
Got4-eq R-LwT NEw f3C7tt_pIN4 — Pao'CS WGP� tJovSE
N Ew F'"46II l5 , P�v�/�ENT SCfI� lMP2ov�MENT S
T. AMOUNT OF LAMP AF�FECTED:
Initiall ' acres ultimately • O acres
6- WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS?
p L Yes ❑No If No,describe bristly
B. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT?
[I Residential ❑Industrial Commercial ❑Agriculture ❑PawFomsUopen space ❑Other
Describe:
10. DOES ACTION INVOLVE A PERMIT APPROVAL OR FUNDING,NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY(FEDERAL
STATE OR LOCAL)?
09 Yes ❑No H yes,list aganey(st and permlllappr ala
WA12-R-Et-4 lG• PL-ANNIN4 f e,!L?
11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL?
❑ 91 Yes No It yes,list agency name and permiUapproVal
12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/APPROVAL REQUIRE MODIFICATION?
❑Yea ❑NO
I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
ApplicanUsponsor name,
� _1 (L1�� Data:
Slgnatum: WAeR t4 T12lff
If the action is In the Coastal Area, and you are a state agency, complete the
Coastal Assessment Form before proceeding with this assessment
OVER
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8/20/02 Site Plan Review
PART II—ENVIRONMENTAL ASSESSMENT(To be completed by Agency)
' A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR PART 617.47 It yes,coordinate the review process and use the FULL EAR
❑Yes ON.
S. WtLL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR,PART 617.67 If No.a negative declaration
may be superseded by another involved agency.
❑Yes ❑No
C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING:(Answers may be handwritten,if legible)
Cl. Existing air quality, surface or groundwater quality or quantity, noise levels, existing traffic patterns, solid waste production or disposal,
potential for erasion,drainage or flooding problems?Explain briefly:
C2. Aesthetic agricultural.archaeological,historic,or other natural or cultural resources;or community or neighborhood Character?Explain briefly:
Ce. Vegetation or fauna,fish.shellfish or wildlife species,significant habitats,or threatened or endangered species?Explain briefly:
Ca. A community's existing plane or goals as officially adopted.or a change in use or intensity of use of lend or other natural resources?Explain briefly
GI Growth,subsequent development,or related activities likely to be Induced by the Proposed action?Explain briefly.
C6. Long term,shoe term,cumulative,or other affect,not Identified in Cl-05?Explain briefly.
C. Other Impacts llncluding changes in use of either quantity or type of energy)?Explain bristly.
D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CEA?
❑Yee ❑No
E. IS THERE,OR IS THERE LIKELY TO BE.CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS?
❑Yes ❑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 amassed in connection with Its (a) setting (i.e. urban or rural); (b) probability of occurring; (C) duration;(d)
Irreversibility;(a)geographic scope;and(1)magnitude.If necessary,add attachments or reference supporting materials. Ensure that
explanations contain sufficient detail to show that all relevant adverse impacts have been identified and adequately addressed. It
question D of Part II was checked yes,the determination and significance must evaluate the potential Impact of the proposed action
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 analysis 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 Lead Agency
Print or Type Name o o I f Res e ice'm Lea Agency it.o esponai a im a
ignature of Reopoivuble Olfioerui Lead Atari ,gnat.'..1 P,e,.,.,( t erent ,we,espom e o ice'
Date
2
1:
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