Application Site Plan Review Revised June 2009
General Information �31G�I2�h
�..
Tax Parcel ID Number:
Zoning District: JUN 06 2011
Detailed Description of Project [include current& proposed use]: j ,.y 1, 'BURY
a
A
TI vft=. OF 0940
Location of project:
LTo d f V&WAl.f_, Lmr oyro
H.W�Q}Q WAC, 0 1-IM W-AQ : UJ M 16t, a. LAa, 810E
Applicant Name: Address:
Home Phone Cell:
Work Phone Fax
E-Mail:
Agent's Name: GU�Ic3 0. r2i?5 aG Address: lot Qf4r. ILU�.
Home Phone kob.6991 Cell: 505, 5691
Work Phone Fax
E-mail 23 00, 60W
Owner's Name foo J PYr Nee, Address iJ7
Home Phone (y (p . 3/p0 Cell
Work Phone Fax
E-mail
Town of Queensbury Planning Office- 742 Bay Road - Queensbury, NY 12804 518-761-8220 2
Site Plan Review Revised June 2009
Site Development Data
Area/Type Existing sq. ft. Proposed Total sq. ft.
Addition sq,
ft.
A. Building footprint �0$2 2&4 154&
B. Detached Garage
C. Accessory Structure(s)
D. Paved, gravel or other hard surfaced area 1647 olb 1141
E. Porches/Decks 4.22 4.22
F. Other
G. Total Non-Permeable [Add A-F] 3 <234 > 02917
H. Parcel Area [43,560 sq. ft. /acre]
gt,3S. Il, 4q(o39.IG
I. Percentage of Impermeable Area of Site [i=G/H]
°�0 90.27
Setback Requirements
Area Required Existing Proposed
Front [1] Sol ( t 56.6,
Front [2]
Shoreline So t y0,& , S0.
Side Yard [1) 1 I [2 ( 12 . 1
Side Yard [2] i ! �. �, 4 3
Rear Yard [11
Rear Yard [2]
Travel Corridor
Height [max]
Permeability
No. of parking spaces
Town of Queensbury Planning Office- 742 Bay Road Queensbury, NY 12804- 518-761-8220 3
Site Plan Review Revised June 2009
Additional Project Information
1. Will the proposal require a Septic Variance from the Town Board of Health? 1 0
2. If the parcel has previous approvals, list application number(s): t70co�-o FAGIU I
3. Does this project require coverage under the NYS DEC Stormwater Pollution Prevention
Program? 00
4. Estimated project duration: Start Date 9 /11 End Date 12/11
5. Estimated total cost of project: *12,=,040
6. Total area of land disturbance for project: 1100 SI=
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 sq. ft.
Existing Floor Area Q s . ft. see above definition
Proposed Additional Floor Area s . ft.
Proposed Total Floor Area sq. ft.
Total Allowable Floor Area Area x see above table
Town of Queensbury Planning Office- 742 Bay Road•Queensbury, NY 12804 -518-761-8220 4
Site Plan Review Revised June 2009
§ 179-9-080 Requirements for Site Plan Aoaroval. 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. Thep o os d pro furthers o is con 'sent with the policies of the Town's Comprehensive Plan,
1
B. The propo ed prtject 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 of 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
co ected to adjacent areas.
D. The site plan must conform to Chapter 136 Sewage and Sewage Disposal, Chapter 147 Stormwater Management Local Law, and
other a liceb e . ; D
E. the proposed use shall be in harmony with the general purpose or intent of thi Chapter,spacificalty laking 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 sil u o Ing public as s anjd acllities whit will follow th ap rov I of the proposed use.
F. The establishment,maintena ce and operation of the proposed use vAll not create public hazards from traffic,traffic congestion or the
packing 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
driv way 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
li,jr& es 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-
08 pf this Article.
I. The Pprovision 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
beivieen adjacent sites shall be provided to encourage pedestrian use.
WA
J. Stomxwater drainage facilities will prevent an increase of post development drainage flows as compared to pre-development drainage
flours. 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
s8ndta![9 of Ch ter 1 7 of the To Co and the Town of Queensbury Subdivision Regulations where applicable.
K. The water supply an sewage disposal f cilities will be adequate and will meet all applicable and current requirements set forth by
e ment 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
veg tation d ma' ten (nGudi g re aoement of des or deceased I nts
14111
a
M. Fire la es, emergency z and fire hydrants will be a uate and t the needs and requirements o emergency service
Mrs.
N. The design of structures, roadways and landscaping in areas susceptible to ponding,flooding and/or erosion will minimize or avoid
su impacts to the maximum extent practicable.
O. The s' plan cenforms 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
§ 179-9-050 Application for Site Plan Review Site Plan Review Revised June 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
fl
A A vicinity map drawn at the scale that shows the relationship of the proposal to existing community facilities which affect or gl
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. W
B The site plan shall be drawn at a scale of forty feet to the inch (l"=40 feet)or such other scale as the Planning Board may �Jl i �+ Z
deem appropriate,on standard 24"x 36"sheets,with continuation on 8'h"x 11"sheets as necessary for written information.
The information listed below shall be shown on the site plan and continuation sheets. �"9"I
C Name of the project,boundaries,date,north arrow,and scale of the plan. S='
D Name and address of the owner of record,developer,and seal of the engineer,architect,or landscape architect. If the .�y�I F a
applicant is not the record owner,a letter of authorization shall be required from the owner �Tr
E The location and use of all existing and proposed structures within the property, Including all dimensions of height and floor g,/j
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, 9
sidewalks, ramps, curbs, paths, landscaping,walls, and fence . S Z
(IJOT 9Fbv/t� = IJA�
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. M IY
H The location,height,size,materials,and design of all proposed signs. �(A
I The location of all present and proposed utility systems including: ✓1xn
1. Sewage or septic system; - Eu Tlt f,,.I..IO !>O�BI� WIZ' 017 �
2. Water supply system; - Lb'a ko>rez q)Q('-fJ c�
3. Telephone,cable,and electrical systems; and � VPL,.I r r 19OLL : �0A;'r ✓-I
4. Storm drainage system including existing and proposed drain lines, cut` e i s, catch basins, headwalls,
endwalls,hydrants,manholes,and drainage swales. p���
J Plans to prevent the pollution of surface or groundwater, erosion of soil both during and after construction,excessive runoff, A
and flooding of other properties, as applicable. A Stormwater Pollution Prevention Plan (SWPPP)for all land development 4
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 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 she where soil remyval or filling is required,showing the approximate volume
in cubic yards. ' Pq t�Z �7 01'21e6Teo 00, gt ,/fi'{'i L'j
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
changes to these features including sizes and types of plants. Water fsources Include ponces wetlands an
watercourses,aquifers,floodplains,and drainage retention areas. fi
I
Town of Queensbury Planning Office- 742 Bay Road • Queensbury, NY 12804 • 518-761-8220 6
Site Plan Review Revised June 2009
M Land Use District boundaries within 500 feet of the site's perimeter shall be drawn and identified on the site plan,as well as
any Overlay Districts that apply to the property. 4% � � WAY( NJZ W&
N Traffic flow 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
for those in heavy traffic areas,which shall 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.
0 For new construction or alterations to any structure,a table containing the following information shall be included: �A
1. Estimated area of structure to be used for particular purposes such as retail 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.
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) I /-
and/or alterations to or expansions of existing facades,showing design features and indicating the type and color of materials V
to be used.
Q Soil logs,water supply well and percolation test results, and storm runoff calculations,as needed to determine and mitigate ` IA
project impacts, 1-+
R Plans for disposal of construction and demolition waste,either on-site or at an approved disposal facility. WA
S Plans for snow removal,including location(s)of on-site snow storage. uA
T An Environmental Assessment Form("EAF"),as required by the SEQRA regulations,with Part 1 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 AWL p J
submitted in conjunction with a special use permit application,a duplicate E4F 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 1
application for all such uses provided the proposed uses are accurately delineated on a site plan drawn pursuant to the IJ&
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
in the Tom's Comprehensive Plan.
Town of Queensbury Planning Office- 742 Bay Road• Queensbury, NY 12804• 518-761-8220 7
Site Plan Review Revised June 2009
Pre-Submission Conference Form r179-4-0401 /
1. Tax Map ID
2. Zoning Classification
3. Reason for Review:
4. Zoning Section#:
S. Pre-Submission Meeting Notes; Outstanding Items To Be Addressed Include:
Deed _Yes _No
General Information complete _Yes _No
Site Development Data Complete _Yes _No
Setback Requirements Complete _Yes —No
Additional Project Information Complete _Yes _No
FAR Worksheet complete _Yes _No
Standards addressed _Yes _No
Checklist items addressed _Yes _No
Environmental Form completed _Yes _No
Signature Page completed _Yes _No
Se jvf'c /o c,t,
T=s E a,-k -?
5 R
dl I u )w+ ��Bvrn- ihswa/r'
Staff Representative:
Applicant/Agent:
Date:
Town of Queensbury Planning Office- 742 Bay Road• Queensbury, NY 12804- 518-761-8220 8
Site Plan Review Revised June 2009
14.104(IINS—Text 13
PROJECT I.D.NUMBER 817.20 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. APPUCANT SPONSOR R. PROJ NA
01
0. PROJECT LOCATION:
Municipality
4. PRECISE LOCATION(Street address and road intaresollons,profnlnant landmarks,No.,or provide magi
b7 HA900 "0 - (::�z\/f,IZ*NLG
QUP.f,I.19�iva� I uar
S. Is PROPOSED AOTI
❑New sion ❑MadllkatbNalMMbn
0. DESCRIBE PROJECT BRIEFLY.
I -c4z 70 SILZLL, FAMIIlr tid`AIOEI.k f.
T. AMOUNT OF D:
ID1tiall acres UItIIMteI
S. WILL PROPOS • CTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS?
❑Yss �Np If No,dew]"briefly
0\\/L jm is '466 I.JG A BIZ \60AOC6
g. VLHF IS PRESENT LAND USE IN VICINITY OF PROJECT?
Wasidential ❑mduatnal ❑Cornmamiti ❑Agriounum ❑ParwForesVopenspaca ❑Dow
DowIN:
10. DOES ACTION INVOLVE A PEftM1T APPROVAL,OR FUNDING,NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY(FEDERAL.
STATE R LOCAU7
AYr ❑No if yes,list apenoyis)and P&MIllapptovais
\\/ IL.j
11. DOES ANY A89ECT OF THE ACTION HAVE A CURRENTLY VAUD PERMIT OR APPROVAL?
❑Yes o x�;1�0 If yes.list agency name and permlitapprmaj
1$. AS A RESULT F ROPOSED ACTION WILL EXISTING PERMITIAPPROVAL REQUIRE MODIFICATION?
❑Yea o
I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
Applkentlspenwr me: (/. DMc
Signature: 9
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
1
Town of Queensbury Planning Office- 742 Bay Road• Queensbury, NY 12804.518-761-8220 9
Site Plan Review Revised June 2009
PART II—ENVIRONMENTAL ASSESSMENT(TO be completed by Agency)
A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN a NYCRR PART(17.4? It yes,coordinate the rand"erggeae and VMS the FULL EAF.
❑Yee ONO
S. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR,PART e17.67 If No.a negative Eaderat"
may be suParaeoad by another in"Iwe agency.
Oyes ONO
C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING:tAnswen may be handwrh, ,if laglblsi
Cl. Existing air quality, surface or groundwater quality or quantity, noise levels, existing traffic pMtems, ads waste production or Claim",
Potential for erosion,drainage or flooding PrOWSMS?Explain briefly:
C2. Aesthetic agricultural.archaeological,historic,or other natural or cultural resources;or Community or neighborhood CharsotaR Explain Warily,
Cq.Vegetation or rams.fish,"Iflah or wildlife epeolas.significant hebitaM w MrOOmW or andangarad s W?Explain briefly:
C4. A oommuNtys existing plane or goals ae officially adopted,or a change in use or Intensity of use of land or other natural neourep7 Explain briefly
CS Growth,subsequent development.or related activities ilkely to be Induced by the proposed action?Explain briefly.
CO- Long term,short term.Cumulative,or other alfaph,not identified M CI-C6?Explain Worry. -
C7. Other ImpaoG(Including changes in use of ekhaf quantity or type of sherry)?E%Pleln briefly.
O. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF CEA7
Oyes ❑No
E. IS THERE,OR IS THERE LIKELY TO OF.CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS?
❑Yea ❑No If Yes,explain briefly
PART lie—DETERMINATION OF SIGNIFICANCE(To be completed by Agency)
INSTRUCTION& Foreach adverse effect ldentlfied above,determine whether It IS substantial,large,Important or otheneurealgniRcant.
Each effect should be atusseed in Contraction with Its (a)setting (i.e. urban or rural);(b) Probability of occurring, (c)duration;(d)
Irreversibility;(e)geographld acopel and(1)magnitude.If naCNsery,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. If
question O of Part 11 well Checked yes,the determination and significance must evaluate the potential Impact of the proposed action
On the environmental eharacteristles 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 6upPOrdng this determination:
Name of LeadAemcy
r nt a Type,Narm,0 fUnponsibl. cer in Lead ApanZ7' Title of Rturpor,ibl.Off.,
bleyetum Of espo,w e Uffloeht.Lead Asnc7— Signature o moamr i erent from ropons Officer)
aG
2
Town of Queensbury Planning Office 742 Bay Road-Queensbury, NY 12804. 518-761-8220 10
Site Plan Review Revised June 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: TON k IAA'( 11WIU-b
Designates: (,U2V5 17.
As agent regarding: Variance_,&_Site Plan Subdivision
For Tax Map No.: 12 Section _] Block Lot
Deed Reference: _Book _Page Date
OWNER SIGNATURE: DATE:
APPLICANT'S AGENT FORM:
Complete the following If the APPLICANT is unable to attend the meeting or wishes to be represented by another
party:
Owner:
Designates:
As agent regarding: _Variance Site Plan_Subdivision
For Tax Map No.: Section Block _Lot
Deed Reference: _Book _Page Date
OWNER SIGNATURE: DATE:
2.) ENGINEERING FEE DISCLOSURE: Applications may be referred to the Town consulting engineer for review of septic
design, stone 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.
4.1 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 applicants 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.
6.1 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, 1 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 1
SALI haver ad and agre tot above. I Ht7y11As/-�'B4k6
' ature [ t] Frrint Name rl [Applicant Dat sQ igred
Signature [Agent] Print N me[Agent] Date signed
Town of Queensbury Planning Office- 742 Bay Road• Queensbury, NY 12804• 518-761.8220 11