Application 1/15/02 • *Plan Re�iew
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General Information MAY 2 9 H'1:2
TOWN OF CU-ENS°URY
PLAN a"1G OFFICE
Application No. (Office Use Only)
Project Location:
Tax Map ID: Z- 1 —24¢
Zone Classification: Peo�Esve, u OGF/of
Compliance with Zoning Ordinance Section:
Detailed Description of Project:
(include current& proposed usel:
Zo 5F M6Q(6-0L dFFICE R'Q1 001/✓S W177!
psSoc/vrEo SrTE Wolx
Modification to existing Site Plan, Yes: No: _ C
(If so,indicate Site Plan No. & approval date)
Square Footage of proposed structure: 3brq zo
Applicant: SG u anent EQ woCN Pea P"-ry ES I ivG
Address: IS F 15fr-pl0. 0ervE
��uE£lV F3v2.'t t-JT 1260¢
Home Phone: -19 A- bG-i 4•
Work Phone/Fax:
Applicant's Agent: Jo,� L-A J� "�ff 5 pPfe e M/LGE
Address: 1 y�yn su ,t5u sran�ST /0 uovitnt✓iv RWI
r r E ors F&M—s t4!r I7AW , r_I T t
Home Phone: 191 Z - Z1 t 7 'lG L^ Oct 58
Work Phone/Fax: F -1I`�1 Z- 5'5� t '19 2 - AS i (
Property Owner: N ff
Address:
Home Phone:
Work Phone/Fax:
Directions to Site:
�os-� Si p� o� �`( Qoao IJc¢rE1 a� 4�nYCeo� /'s uTE�
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1/15/02 • Solan Review
Site Development Data
Area/Type Existing sq. ft. Proposed Addition Total sq. ft.
sq. ft.
A. Building Footprint
O I'1, 360 I"1, 360
B. Detached Garage
D o 6
C. Accessory Structure(s)
G O o
D. Paved, gravel or other
hard surfaced areas
E. Porches/Decks
p a d
F. Other
Total Non-Permeable
Sum A through F 901 ¢Z$ 90,¢ZS
Parcel Area 22G,er`1S Z26f 5-
Percent Non-Permeable
Total Non-Permeable/Parcel Area) • 8� 39•$�
Setback Requirements
Required Existing Proposed
Front 1 — Z 39.'L
Front 2
LdeY Side Yard 1 —
Side Yard 2 10 76•/
Rear Yard 1 — —
Rear Yard 2
Buffer/Travel Corridor 125, r -16.11
Height o 5 L
Permeability ' — .Z
Si Setback
No. of Parking Spaces
1/15/02 • Siolan 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 our application
PR NA WR
GENERAL
A. Title,name, address of applicant&person responsible for preparation of drawing
v B.North arrow,Tax Map ID,date prepared and scale(minimum 1 in.=40 ft.)
t� 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.
r 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
lr 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
v material e. ., gravel,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
F.Lighting,location and design of all existing or proposed outdoor lighting
ADDITIONAL SITE DEVELOPMENT AND MISCELLANEOUS
A.Location of on-site&adjacent watercourses, streams,rivers,lake and wetlands
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,
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
c. E. Signage: Location,size,type,design and setback
F.Waiver Request: provide letter with application requesting any waivers
n G. Commercial / Industrial Development requires submission of a Landscaping Plan, Stormwater
�V> Management Plan,Grading Plan and a Lighting Plan
H. The Bd.may request other elements as considered necessary.
tr I. Identify any Federal, State or County permits required for the project.
J. Please submit record of application for approval status of all necessary permits required from Federal,
State and Coun officials.
Legend: PR—Provided; NA—Not Applicable; WR—Waiver Requested
ID
1/15/02 • • Site Plan Review
i4,lia n,195)—Text,z _
• PROJECT I.D.NUMBER 617.20 SEOR
Appendix C
State Environmental Quality Review
SHORT ENVIRONMENTAL ASSESSMENT FORM
For UNLISTED ACTIONS Only
PART 1—PROJECT INFORMATION(To be completed by Applicant or Project sponsor)
1. APPLICANT ISPONSOR 2. PROJECT NAME
RME2NoRJV •j'ILaS
5, PROJECT LOCATION:
Munlclwnty E1'j5e cotwity �!✓ IP-EN
A. PRECISE LOCATION lStroat address and road InGrasetlons•prominent landmarks,etc,or proMde inapt
PAY 20'Ap 061 F-A s-r Si PE
'wo-m-+ aF Ae:r—
5. IS PRO ED ACTIN:
Wew ❑Expansion ❑Modlileattonlaberallon
S. DESCRIBE PROJECT BRIEFLY: .
331`17-0 SF pFfic� (3vfc�f�< �ssacro7ito
s�LJjvae�
T. AMOUNT OF LAND AFFECTED:
initially '.S•Z sUea Ultimate S•� acre.
B. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS?
Klee ❑No If No,descrlbe brbfty
e. WHAT IS PRESENT LAND USE IN VICINITY t� 6
O�1/ T?F PROJEC
UZRssildenb r.7a
al ❑lnduatdal —nmlal ❑Agdoultun ❑Parkwomuopen space ❑Dow
Descdba.
10. DOES ACTION INVOLVE A PERMIT APPROVAL.OR FUNDING,NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY IFEDERAL,
STATE OR LACALI7❑ 'Yes o If yes,list agency(s)and perma/approvals
I,. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VAUD PERMIT OR APPROVAL?
❑Yea 0 If yes,Bat agency name and pemtftlapprwal
12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMITIAPPROVAL REQUIRE MODIFICATION?
❑yes No "A.
I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
Appikantl � 'e sponsor ,n/anme: �i C'� ` - ^ -C`M'a'A-^/J �� Dale:
Signature: •'^�• �' 1
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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1/15/02 • Site Plan Review
• PART 11—ENVIRONMENTAL ASSESSMENT(To be completed by Agency)
' A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN a NYCRR PART$17.47 It yea,Coordinate the review Process and use the FULL W.
❑Yea ❑No
B. WtLL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR,PART 817.6? If No,a hoped"declaration
MY be superseded by another Invoked agency.
❑Yes ❑No
C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING:(Anse may be handwritten,If laglbkJ
Cl. Existing air quality. surface w groundwater quality or quantity, noise levels, existing traffic patlems, solid waste production a dtsposaL
potential for erosion,drainage Or flooding Problems?Explain briefly:
C2 Aesthetic agricultural archaeological,historic,or other Mlural Or cultural resources:or community or neighborhood character?Explain briefly:
W. Vegetation or fauna,fish,shellfish or wildlife species,significant habitats,pr threatened or endangered species?Explain briefly.
C4. A community's existing plans or posts as officially adopted,or a change In use Of Intensity of use of land Of ether natutal resources?Explain briefly
C6. Growth,subsequent daysbpment,or related agtkltlm likely to he Induced by the proposed action?Explain briefly.
Ca. Long term,short term,cumulate,or other effects not Identified In Cl-CS?Explain briefly.
C7. Other Impacts(Including changes In use of either quantity or type of erwrgy)?Explain briefly.
D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF CEA?
❑Yea ❑No
E IS THERE,OR 15 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 affect Identified above,determine whether R Is substantial.large,important or otherwise significant.
Each effect should be assessed In connection with Its(a) setting(Le. urban or rural (b) probability of.occumng;(c)duration;(ci
Imererelblllly;fe)geographic Scope;and M magnitude.If necessary,add attachments or reference supporting materials.Ensure that
explanations contain sufficient detail to show that all relevant adverse Impacts haw been IdonilRed and adequately addressed.H
question D of Part 11 was checked yes,the determination and significance must evaluate the potential Impact of the proposed action
on the environmental charactorlstica of the CFA
❑ 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:
N..of LeadAgency
Punt or Type Name o ItsOonulbl.Office,in Lead A'encY Titie o e Otficer
.Mature of ltespom.ble Uifaer la Lead A'sncy .'nature of prepare, . gent 1. espornibit o icer
Dat•
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1/15/02 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
Owner: Qic WA-00 �xw r><¢Ho�N Jam•
Designates: Jew PPE¢ F54 , SANEs A?4, €V_ -["O%A� NEE
As agent regarding _Variance_Site Plan _Subdivision
For Tax Map No.: _Section _Block _Lot
Deed Reference: Book Page _Date
SIGNATURE: /- �C�(�- l� (Owner) S 9-02(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
Owner:
Designates:
As agent regarding: _Variance _Site Plan _Subdivision
For Tax Map No.: _Section _Block _Lot
SIGNATURE: (Owner) (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.
I,the undersigned, have thoroughly read and understand the instructions for submission, agree to
the submission requirements and completed t)le checklist.
SIGNATURE OF APPLICANT: -Date S ' Y ' p Z,
SIGNATURE OF AG EN : -Date S�
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