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Application FILE COPY �o/ay lq7 TOWN OF QUEENSBURY DEPARTMENT OF COMMUNITY DEVELOPMENT SITE PLAN REVIEW APPLICATION APPLICATION NO. y� �18p.97 I. APPLICANT: P-113 C06 d� � �L1. <�J/�lR-U_(V1. lzVock WA�� ADDRESS: Phone #: Home _ 7 7 7 Phone #: Work 7 APPLICANT'S AGENT: ADDRESS: Phone #: Home Phone #: Work PROPERTY OWNER: O�u d J LlU ADDRESS: Phone #: Home Phone #: Work 4p PROPERTY LOCATION: i9 k J� u e �J iea �I/S lj y TAX MAP NO. I I ZONE CLASSIFICATION: C I� n DE CRIPTION OF OJECT: STO)Q ncl 112E D DIRECTIONS TO THE PROJECT (fQr Board members & Staff to locate p of Mt for she vi is• F�ok P fQ A 4 JP Pi ( CUbSS i (tom 1l , C- . ' -2- II SITE DEVELOPMENT DATA �7 Tax Map Number: Section II ` Block ` Lot / Zone Classification: Area of Parcel acres = sq. ft . Maximum Size Building Allowed sq. ft . Disposition of Parcel : Existing v f!l Building Area sq. ft . % of parcel Paved Area sq. ft . % of parcel (including walks) Green Area sq. ft . % of parcel Proposed Building Area sq. ft. % of parcel Paved Area sq. ft . % of parcel (including walks) Green Area sq. ft. I % of parcel Building Setbacks — Noc1r, r- Existing Proposed Required Front Yard Front (if corner) Side Yard (1) Side Yard (2) Rear Yard Rear Yard (2) Shoreline Width Depth Access (check where applicable) Town Highway LI County State Length of Frontage a qo ID Number of ParkV spaces : Existing Proposed GS Town Water: Yes No Town Sewer: Yes � No Any previous Planning or Zoning Board determination regarding this property? (� Present Use of Property- Proposed Use of Property: 24 kLts SToPF -3- APPLICANT PLEASE READ AND SIGN BELOW A COMPLETE APPLICATION IS NECESSARY FOR PLACEMENT ON THE PLANNING BOARD AGENDA. The Planning Office requires : 1Q copies of your site plan application, maps, and supporting documentation - 1 original and 9 copies 2 copies of the deed and survey plat . The fee for site plan review is $25 ,00. Applications may be referred to the Town consulting engineer for review of septic design, storm drainage, etc . The applicant is required to pay for the costs associated with this review. The hourly rate charge for the engineering review will be charged directly to the applicant . Fees for engineering review will not exceed $1, 000 .00 without notification to the applicant . Other permits may be required for construction or alteration subsequent to approval by the Planning Board. It is the applicant' s responsibility to obtain these. i, the undersigned, have thoroughly read and understand the instructions for submission, agree to the submission requirements and completed the checklist. Furthermore, it is the practice of the Department of Community Development to have a designated stenographer tape record the proceedings of meetings resulting from applications, 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. I HAVE READ AND AGREE TO THE ABOVE STATEMENT Applicant' s Signatur. -Z�- Date 10 --1 _9 Applicant' s Agent Signature Date (if Authorization to Act as Agent form has been signed) -4- AUTHORIZATION TO ACT AsA HNT If the APPLICANT is unable to attend the meeting, or wishes to be represented by another party, the applicant' s signature is needed on the authorization form below, designating an agent. APPLICANT' S AGENT FORM I, , hereby designate as my agent regarding Site Plan, Subdivision application For Tax Map Number: Section , Block , Lot SIGNED: DATE: If the OWNER of the property is not the same as the applicant, the owner' s signature is needed on the authorization form below, designating the applicant as agent. OWNER' S AGENT FORM owner of premises located at Tax Map Number: Section I/L, Block I, Lot rf_L hereby designate as my agent regarding an application for a Site Plan, Subdivision at the above premises . S IGNED: DATE: Z�4,1 5P�1 Deed Reference: Book Page Date -5- SITE PLAN REVIEW CHECKLIST The Plot Plan: Draw to scale (1 inch = 40 feet or less) a detailed description of the proposed site . Failure to include all the required information on your site plan will result in a determination of incompleteness and a delay in the processing of your application. * Items A through M must be included on the Plot Plan for the site plan review application. * Items N through Z shall be included on the Plot Plan if applicable. P N/A A. Title of drawing, including name and address of applicant and persons responsible for preparation of such drawing. B. North arrow, scale and date . C. Boundaries of the property with dimensions in I feet, including zoning boundary delineations . D. Location of all existing principal and accessory structures and their uses with exterior dimensions and lot line and waterfront setback. E. Location of all proposed principal and accessory uses and structures with exterior dimensions and lot line and waterfront setbacks . F. Location of any existing or proposed driveways, outdoor storage areas and refuse containment areas, including setbacks and dimensions of the structures . G. Location of existing and proposed sewage disposal facilities including lot line, waterfront and well setbacks . For proposed system, or if expanding use, include design details, construction materials, flow rates or number of bedrooms served and percolation test results . Also, location of existing sewage and water systems on adjoining lots . H. Location and description of existing public or private water supply. -6- I . Description of the method of securing public I or private water and location, design, and construction materials of such facilities . J. Total number of existing parking spaces, including the number of those to remain on to be removed, those to be paved, those to be graveled, and total number of proposed new paved spaces and proposed graveled spaced, including basis for determining parking adequacy. K. Location and design of all existing and proposed outdoor lighting facilities . L. Percent of lot which is presently permeable, including composition of ground cover (grass, shrubs, gravel, etc. ) M. Percent of lot which is proposed to be permeable, including composition of ground cover. N. Existing watercourses, wetlands, and other waterbodies . O. Proposed maximum daily water usage in gallons per day. P. Location and design of all existing and proposed parking and loading areas, showing driveways, igress, egress, handicapped parking and curbing. For proposed parking and loading areas, include design details, construction materials and dimensions . Q. Provision for pedestrian and handicapped access . R. Location, design and construction materials of all existing or proposed site improvements including drains, culverts, retaining walls, and fences. T S . Location of fire and other emergency zones, Iincluding the location of fire hydrants . T. Location of all existing and proposed energy distribution facilities and other utilities, including electrical, gas, solar energy, telephone, etc . For proposed facilities, include design details and construction materials . -7- U. Location, setbacks, size, design and type of all existing and proposed signs, including design and construction details of proposed signs . V. Location and proposed development of all buffer areas, including existing vegetation cover and screening of storage or refuse areas . W. identification of the location and amount of building areas proposed for office, manufacturing, retail sales or other commercial activity. X. General landscaping plan and planting schedule, including existing trees over 3 inches in diameter. Y. Grading and stormwater management plan, showing existing and proposed contours and including drainage calculations . Z . Other elements integral to the proposed development or considered necessary by the Board and staff . P - Provided N/A - Not Applicable -8- 14:16-4 W951—Text 12 'ROJECT I.D. NUMBER 617.20 SEC 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) . EMOUNT CANTSNNSOR ` 3 rYl 2. ROJECT NAME ' Ivy uc `2 � TiVL)CK t/�ECT LOCATIJON: unicipality I^ 2 � County ISE LOCATION(Street address and road Inleraectlons, prominent landmarks• etc., or provide map).� 12 � IY, Q \je A���125e 7;on�� mix fl �e <t Dhll � Ve . �'o sS �POSED ACTION: New ❑Expansion ❑ModlIlCatlonlalterallonIBE PROJECT BRIEFLY:s sT OF LAND AFFECTED:tY aerea Ultimately sues - a. WILL ITO POSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICNs? /ffYes ❑No It No,descrlbe briefly 9. WHAT 1S PRESENT LAt�1Oe�+USE IN VICINITY OF PROJECT? ❑Residential tCtlnduatrlal ❑Commends! ❑Agriculture OParmnistl0pen aPaa ❑Otter-Da"d 10. DOES ACTION INVOLVE A PERMIT APPROVAL OR FUNDING NOW OR ULTDAATELY FROM ANY OTHER GOVERNMENTAL AGENCY(FEDERAL, STATE OR LOCAL / ❑Yea Nd if yea,list at ency(s)and permlUappmvals _. r1t2- DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PFR Mrr OR APPROVAL? ❑Yes "No If yes,list agency name and permlVapproval AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMrrrAPPROVAL REQUIRE MODIFICATIOM - ------- --'-' ❑Yea .- ONO' No ... .. _ ._ I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGEDate APPllcant/sponsor name. 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 PART II—ENVIRONMENTAL ASSESSMENT (To be completed by Agency) y A. G�''EEIIS ACTION EXC D ANY TYPE I THRESHOLD, IN 6 NYCAR, PRAT 617.<? t Lt Yes 11 yes, coprtlmale iris renew process and me the FULL EAF. No B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCAR.PART 617.6? 11 Na,a negative declaratior may be superseaed another involved agency. Yes �No C. CC1.OULD ACTN RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING:(Arawers may be handwritten. If legiblet EzisIO ting air quality. surface or groundwater quality Of quantity. noise levels, existing traffic Patterns. solid waste Production or disposal, Potential to( erosion,drainage or flooding problems? Explain briefly: No C2. Aesthetic, agricultural.archaeological,historic,or other natural or cultural resources;or community or neighborhood character?Explain bneft} C3- Vegetation Or fauna.fish,shellfish or wildlife species,significant habitats, or threatened Of endangered species?Explain briefly, - CA. A community's existing plans ar goals as officially adopted,or a change in use or Intensity of use of land or other natural resources?Explain briell) /V U C5. Growth, subsequent develaoment,of related activities likely to be induced by the proposed action? Explain briefly. /Ud CS. Long term, short term,cumulallre,or other ellects not Identified In Cl-CS7 Explain briefly. /Ud C7. Other Impacts(Including Changes In use*of either quantity or type of energy)? Explain briefly. D. WILL THE PAOdrEUTT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CEA? ❑Yes U No E. 15 THERE, OR IS THERE LIKELY TO aE,CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? ❑Yes *ONO If Ye;explain briefly PART III—DETERMINATION OF SIGNIFICANCE (ro be completed by Agency) _ t- INSTRUCTIONS: For each adverse affect Identified above,determine whether It IsSubstantlaklarge.Important orethervHseSignificant. �* Each effect should be assessed In connection with Its (a) setting (Le. urban or rurafk (b) probability of occurring; (c) duration; (d) Irreverslbillty;(e) geographic scope;and(1) magnitude- If necessary, add attachments or referenda supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse Impacts have been Identified and adequately addressed. If question D of Part It 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 o Lea Agency � Mt Name Or Aelponlr a icer In Lea Agency , Responsible— _ a (car Ar , , 4 tin O{NC1pOM' a MNR Y a (<Pam(if diffenrat from(elpOnn a OI KRI -51> are —