Application FILE COPY
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TOWN OF QUEENSBURY
DEPARTMENT OF COMMUNITY DEVELOPMENT
SITE PLAN REVIEW APPLICATION
APPLICATION NO.
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�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- . '
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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
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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)
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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
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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.
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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 .
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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
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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
_.
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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
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are —