3.5 .!
3.5
ZON NG\Rezoning App to Planning Board and Request Lead Agency Status—Masonic Historical Society—8-9-2021
RESOLUTION AUTHORIZING TOWN CLERK TO SUBMIT
QUEENSBURY MASONIC HISTORICAL SOCIETY'S
PETITION FOR CHANGE OF ZONE APPLICATION TO QUEENSBURY
PLANNING BOARD AND SEEKING SEQRA LEAD AGENCY STATUS
RESOLUTION NO.: 92020
INTRODUCED BY:
WHO MOVED ITS ADOPTION
SECONDED BY:
WHEREAS, the Queensbury Masonic Historical Society (QHMS) submitted a
zoning change application to the Queensbury Town Clerk's Office on or about July 30, 2021
to allow for the addition of Day-Care Center as an allowable use by Site Plan Review in the
Neighborhood Residential Zoning District, and
WHEREAS, the application has been reviewed by the Town Senior Planner and
deemed complete for purposes of review, and
WHEREAS, applications for zoning changes are subject to Warren County Planning
Department review in accordance with §239-m of the New York State General Municipal
Law,and
WHEREAS, applications for zoning changes may be forwarded to the Town Planning
Board for recommendations in accordance with §179-15-040 of the Town Zoning Ordinance,
and
.p
WHEREAS, following such recommendations, the Town Board will review the
application and take such other action as it shall deem necessary and proper, and
WHEREAS, prior to making a decision about whether to approve the zoning change,
it is necessary to conduct a review under the New York State Environmental Quality Review
Act (SEQRA) for potential environmental effects,
NOW, THEREFORE, BE IT
RESOLVED, that the Queensbury Town Board hereby declares its intent to seek Lead
Agency status for SEQRA review of the proposed zoning change requested by the Queensbury
Masonic Historical Society (QMHS) as delineated in the preambles of this Resolution, and
BE IT FURTHER,
RESOLVED, that the Town Board hereby authorizes and directs the Town Clerk to
forward QMHS's application received by the Town Clerk's Office on or about July 301h to
the Queensbury Planning Board for review, report and recommendation, and
BE IT FURTHER,
RESOLVED, that the Town Board further authorizes and directs the Town Clerk to
submit the application to the Warren County Planning Department for NYS GML §239-m
review, and
BE IT FURTHER,
RESOLVED, that the Town Board further authorizes and directs the Town Supervisor
to execute any necessary documentation and the Town's Department of Community
Development to notify, if and when appropriate, any other Involved Agencies of the Town
Board's intent to serve as Lead Agency for SEQRA Review of the project and the Town
1
Supervisor, Town Clerk and/or Department of Community Development to take any other
necessary actions to effectuate the terms of this Resolution.
Duly adopted this 9fl'day of August, 2021 by the following vote:
AYES
NOES
ABSENT
MEYER,
FULLER &
STOCKWELL P L L C LAKE GEORGE
�� 1�J
.i JUL 3 0
r..^^Irrr URY
NS8
July 30, 2021 kqp
Town Board, Town of Queensbury
742 Bay Road
Queensbury,New York 12804
Re: Queensbury Masonic Historical Society Zoning Request
Dear Supervisor Strough and Members of the Town Board:
Following my discussions with Stu Baker, I enclose herewith revised application documents for
the proposed zoning change to permit day-care use in the NR zone.
As you know, our firm has been working with the Queensbury Masonic Historical Society with
regard to the zoning of its property at 15 Burke Drive. The Historical Society has received a
proposal from a proposed tenant to operate a day-care center at a portion of the property. The
property, in addition to housing the Historical Society's museum, has housed a preschool in the
past. We believe a day-care center is complimentary to this past use.
The proposal is to add "Day-care Center"to the Neighborhood Residential Zone as defined and
provided for in Chapter 179 of the Code of the Town of Queensbury (the "Zoning Law"). We
believe that this use would meet the current demands of society in general in the post-Covid
employment world. Day-care is often sited as one of the bigger impediments to parents returning
to work, with minimal impact to the Neighborhood Residential zone in general. In reviewing the
Town's zoning map, it appears that this use would be reasonable as to the properties included in
the zone.
Attached are the following exhibits:
1. Chapter 179 Attachment 2- Summary of Allowed Uses in Residential Districts;
2. Chapter 179 Attachment 3- Summary of Allowed Uses in Commercial Districts;
3. Zoning Map.
4. Full SEQRA EAF Form.
The schedules of uses for the residential districts under current Chapter 179 are set forth at
Exhibits 1 and 2, respectively. They reflect that the day-care use is not allowed currently in the
NR zone. The proposal is to permit it following site plan review by the planning board. That
Meyer, Fuller$Stockwell, PLLC 1557 State Route 9, Lake George, NY 12845 518.668.2199 meyerfuller.com
- way any impacts:to surrounding:uses.or properties.cari be considered by the board, and a:public. ..
hearing held. For the board'sreference;we have supplied:the current zohing map.for the Town at
Exhibit 3, and:a full.EAF at Exhibit 4: -.
The application.fee of$2.50 h s been-pai0o.-the-Town: We appreciate the.Town Board's.
consideration of this request:.' :-
It.'is:submitted-that if the zoning change is.appr&ed,-anyactual use of my client's
:property.
would-be:the subject of a separaie.sife plan appticatiori.:.'
Please note that Lwill.be out of state_working_remotely thc*period from August 19.through
= 'September S. If the Town permits.appearance.in its meetings via Zoom or other platform-
during that time, I Would be happy to appear: If riot;reprp96ntative.s of the Association maybe
able to appear as well...
.-Thank you: -
Sincerely,
Matthew F.Buller,Esq. .
infulier ,meyerfuller.com
Meyer,Fuller&Stockwell, PLLC • 1557'State Route 9,Lake.George, NY 12845 • 5'18.668.2159 megerfuller.co.m
Revised Oct.2008
TOWN OF QUEENSBURY TOWN BOARD APPLICATION
PETITION FOR CHANGE OF ZONE
Petition No.(Office Use Only):
Applicant's Name: QUEENSBURY MASONIC HISTORICAL SOCIETY
Address: 15 BURKE DRIVE,QUEENSBURY,NY 12804
To the Applicant:
The Queensbury Planning Board will review this Petition and make recommendations to the Town Board. As
part of this review, the Planning Board will consider the following questions and submit answers to the Town
Board. As the applicant, you will have the option to provide answers for the Boards to consider.
1. What need is being met by the proposed change in zone or new zone?
Proposed change would permit daycare in the Neighborhood Residential Zone
2. What existing zones, if any, c�n meet�ie stated need?
Daycare is not currently hste as an owe use in any residential zone.
It is permitted in the CM,CI,ESC,MS,NC and 0 zones.
3. How is the proposed zone compatible with adjacent zones?
Adjacent zones do not appear to be impacted at all by the proposed request.
4. What physical characteristics of the site are suitable to the proposed zone?
Not applicable to request
5. How will the proposed zone affect public facilities?
The post Covid world has seen an increase'in the need for daycare.facilities
and this site has been a preschool in the 12ast(see exhibits).Daycare would
;fit;p .with this pr; r use and not impact adininina nropprties
.6. Why is the current zone classification not.appropriate for the property in question?
T)ngc not permit dy car
7. What are the environmental impacts of the proposed change?
We can identify no enyirQnmental impacts from the proposed change.
1
Revised Oct.2008
8. How is the proposal compatible with the relevant portions of the Comprehensive Land Use Master
Plan?
Tn rPviPwino the CLUMP we-believe the use is in harmony with the NR zone.
9. How are the wider interests of the Community being served by this proposal?
.As noted the pnQt Cmrid umrld demands better arress to daycare_ RF n? its
itre �g- a-; sitrt� a�ti�e a g-pn�iiisa��-� i��d daysaxg
economy.
These questions are based on criteria used to review all zoning amendments.
2
Revised Oct.2008
Application-Petition for Change of Zone
The applicant must submit a fee of $250 with the original & seventeen (17) copies of all documentation
requested in this application to the Town Clerk's office. [Copies are distributed as follows: Town Board (5),
Town Clerk(1), Town Counsel (1), Planning Board (9), File Copy(1), and Planning Staff(1).
Petition No. (Office Use Only):
Date Received by Town Clerk:
Date Received by Planning Office:
1. Application For: (check where applicable)
Amendment of Zoning Map
Amendment of Zoning Ordinance
2. Current Zoning: NR
Proposed Zoning:
3. Project Location: Town Wide
4. Tax Map ID:
5. Applicant:
Address:
Phone: 518-745-8216
6. Applicant's Agent: Meyer,Fuller&Stockwell,PLLC
Address: 1557 State Route 9,Lake George,New York
Phone: 518-668-219
7. Property Owner: Same as applicant
Address:
Phone:
8. Directions to Site:
9. Statistics and Data on Property:
a. Total Area: sq.ft. or acres
b. Dimensions:
Minimum Width:
Average Width:
Minimum Depth:
Average Depth:
3
Y
Revised Oct.2008
Physical Irregularities (describe): None noted
C. Existing use(s): include structures, outdoor uses, rights of way, easements, deeds and
limitations to use of property:
d. Adjacent uses within 400 feet: (state direction, location, use, zone&owner):
e. State, County or Town property within 500 feet:
NA
10. A Map/Survey of the property to be rezoned must be submitted With the application; ite s A through H
must be included on the plan and addressed in the submission Waiver from survey update requested
A. Map of property at a scale of 1 inch=40 feet or less with scale, north arrow and topography.
B. Boundaries of property with dimensions in feet, including zoning boundary.
C. Identification of wetlands, watercourses or waterbodies on site.
D. Location of any current structures on site, their exterior dimensions, use and setbacks.
E. Location of any proposed easements and driveways.
F. Location of existing public or private water and sewer facilities.
G. Location of existing and proposed parking and loading facilities.
H. Identification of uses(i.e. residential, commercial, industrial) on property within 500 feet.
11. If Petition is for an amendment to Zoning Ordinance, cite the section(s)to be changed, and wording to
be substituted: 179 Attachment 2,Daycare in the NR zone by SPR(site plan review)
12. In support of this petition, the following statement is made:
More access to daycare is needed by the public in the post-Govid local economy.
13. The following documents are submitted herewith:
See letter and exhibits.
4
Revised Oct 200B
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:
Designates:
As agent regarding: Variance Site Plan Subdivision
For Tax Map No.: —1Section 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: Queensbury Masonic Historical Society
esignates: Meyer,Fuller&Stockwell,PLLC
As agent regarding: Variance Site Plan Subdivision Zoning change
For Tax Map No.: 32M Section 4- Block W Lot
D efere Book 2r, Page 6 'Date
OWNER URE: DATE:
2.) 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.
3.) 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.) 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 applicant's responsibility to obtain any additional
permits.
6.1 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) AGREEMENT TO PROVIDE DOCUMENTATION REQUIRED: 1, 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, I 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
I have read and agree to the above.
SIGNATURE OF APPLICANT: DATE:
SIGNATURE OF AGENT: E. 7 �i
5
ZONING}
179Attrrchment 2
Town of Queensbury
Table 2:Summary of Allowed Uses in Residential Districts
[Amended 12t1•2011 by L.L.No.g 2011;3-18-2013 by L.L.No..2-2013;7-21-2014 by L.L.No.2 2014;4-20-2015.by L.L.No.2 2015,
5-&2014 by L.L.No.4-2019;1 25-2021 by L.L.No.1-20211
KEY
AU = Accessory Use or Structure
PU = Permitted Use
SPR = Site Plan Review Use
SUP = Special Use Permit Required
Blau '-. Not Permitted
Land Moderate Density Neigbborhood Parkland Rural Waterfront
Conservation Residential Residential Recreation Residential Residential
LC-10 PR-10 RR-3
Residential Use Fable LC-42 MDR NR PR 42 RR-5 VTR
Agricultural servicetretail SPR SPR
Agricultural use SPR SPR SPR
Bed-and-breakfast SPR SPR SPR SPR SPR
Boat storage facility SUP SUP
Boathouse SPR
Campground SUP
Cemetery SPR SPR SPR SPR
Class A marina Sups
Class B marina
179 Attachment 2:1 sip 74,Feb 2o2i
L
QUEENSBURX CODE
Land- Moderate Density Neighborhood Parkland Rural Waterfront
Conservation Residential Residential Recreation Residential Residential
LC-10- PR-10 RR-3
Residential Use Table LC-42 MDR NR PR-42 RR-5 WR
Commercial boat sales/service/storage SUP
Condominium development or unit PU SPR
Day-care center
Duplex PU' PV PU3
Food service SUP
Golf course and/or country club SUP
Golf driving range 5UP
Group camp SPR SPR
Home occupation PU AU AU AU AU
Kennel SUP SUP
Library SPR SPR SPR
Mobile home' PUc PU'
Motel SUP
Multifamily dwelling SPR SPR
Nursery SPR SUP SUP
Outdoor recreation SPR SPR SPR SPR
Personal service SUP
Place of worship SPR SPR SPR SPR SPR SPR
Playground SPR SPR SPR SPR
.179 Attachment 2:2 Svpp 74,Feb 2021
ZONING
Land Moderate Density Neighborhood Parkland Rural Waterfront
Conservation Residential Residential Recreation Residential Residential
LC-10 PR 10 RR-3
Residential Use Table LC42 MDR. NR FR-42 RR-5 WR
Private school SPR SPR SPR
Produce stand.less than 100 square feet PU PU PU PU PU PU
Produce stand greater than 100 square feet SPR SPR SPR SPR SPR SPR
Public or semipublic building SPR SPR SPR SPR SPR SPR
Riding academy SPR SPR SPR
Sand,gravel and topsoil extraction, SUP°
commercial -
Sawmill,dripping or pallet mill SUP SUP
Single-family dwelling PU/SPRY PU PU PU PU PU
Sportmen's clubm firing range SUP
Townhouse SPR
Tree service/landscape company SUP
Veterinary clinic SPR SUP SUP
Water extraction SPR
Allowed within Mobile Home Overlay District;additional regulations apply.
Site plan review required for properties within the Adirondack Park.
' Moxe than one duplex per parcel requires site plan review.
1 Limited to parcel sites of 25 acres or greater.
Class A Marinas not allowed on Glenn Lake,Sunnyside Lake and Dream Lake.
179 Attachment 2:3 Sspp 74,Feb 2021 .
ZOhINNO
179 Attachment 3
Town of Queensbury
Table 3:Summary of Allowed Uses in Commercial Districts
jAmended 4-19-2010 by L.L.No.7-2010;128-2011 by LJL No.2-2011;4-12013 by L.L.No.3-2013;
12-16•-2013 by L.L.Na 7 2013;7-21-2014 by L L.No.2-2014;10-6-2014 by LZ.No.5-2014;9-14-2015 by LJL No.5-2015;4-18 2016 by L.L.No.
3-2016;10-172016 by L.L.No.7 2016;6-1-2020 by I.L.No.6-20201
ICE'S
AU P Accessory Use
PU = Permitted Use
SPR = Site Plan Review Use
SUP Special Use Permit Required
Blank Not Permitted
Enclosed
Commercial Commercial Commercial Shopping Main Neighborhood Recreation
Moderate Intensive Intensive-Exit 18 Ceater StreetO) Commercial llffKe Commercial
Commercial Use Table CK CI CC 10 ESC MS NC 0 RC
<600 feet 2 0Q feet
from arterial from
arterial
Amusement center i SUP SUP SPR SPR
Apartment house SPW
A enthouse/condos SPRIo SPRM
Apartment house above SPR'
first floor
AWImeathouse/condos SPR SPRO
above first floor
Auto bo!!yhepak shop SPR
Automobile service SPR SPR SPR
Automotive Saks and SPR SPR SPR
service.
Bank SPR. . SPR SUP SPR SPR SPR SPR SPR
Business service SPR SPR SUP SPR SPR SPR SPR SPR
Campground SPR
t79 Attachment 3:1 Sapp 7L aan 2M
;i r 4
QUEENSBURY CODE
Enclosed
Commercial Commercial Commercial Shopping Main Neighborhood Ptecreation
Moderate Intensive Intensive-Exit 18 Center Streeto) Commercial Ofee Commercial
Commercial Use Table CM CI CI 18 ESC MS NC 1 O RC
-46M feet ?600 feet
from arteriat llrom
arterial
Carte SPR SPR .
Cemetery SPR
Commercial boat SPR SPR
salesIservice/storape
Convenience store SPA SPR SUP SPR SPR SPR SPR SPR
Convention,sports or SPR SUP SUP SPR SPR SPR. SPR
exhibit center
Day-care center SPR SPR SPR I SPR SPR SPR SPR
Drive-in theater SPR
Enclosed shopping center I SUP
Fast-food establishment I SPR SUP SPR I SUP
Fixing mite,indoor I SUP
Food service I SPR SPR SUP SPR SPR I SUP AU AU SPR
Funeral home SPR SPR
Gallery SPR SPR SPR SPR SPR SPR
Golf course SPR SPR
GoIf driv' r e SUP SUP
Health-related Ifthaity SPR SPR SUP SPR SPR SPR SPR
Kennel SUP SPR
Lib SPR SPR
Limousine service SPR
Live theater SPR SUP SPR SPR
Microbrewry SPR SUP SPR SPR
Mineral extraction SUP
Mobile home sales SPR
Motel SPR SPR I SUP SUP SPR
Movie theater SPR SPR SUP SPR SPR
Multifamruy SPRM SPW
house/condos
Munici center SPR SPR
Mum SPR SPR 1 SPR SPR
Nightclub SUP SUP SPR I SUP
179 Attachment 3:2 Sapp n,den 2W
ZONING
Enclosed
Commercial Commercial Commercial Shopping Main Neighborhood Recreatlon
Moderate Intensive Intensive-Eaut 18 Center Streeter Commercial Office Commercial
Commercial Use Table CM CI CI 18 ESC MB NC O RC
<600 feet >_600 feet
from arterial from
arterial
Nursery SPR SPR
Office,1 0) SPR SPR SUP SPR I SUP SPR(1) SPRW
Ofim small SPR SPR SUP SPR I SPR SPR SPR SPR
Outdoor concert events SPR SUP
Paitrtball facility SUP
parking lot SPR SPR SUP SPR
Parking structure SUP SUP SUP SUP SPR SPR SPR
Personal service SPR SPR SPR SPR SPR AU AU
Place of Worship SPR SPR SPR SPR SPR SPR
Playground SPR SPR SPR
Produce stand SPR SPR SPR SPR SPR SPR
Public or setnipublic SPR SPR SUP SPR SPR SPR SPR SPR
building
Recreation center. SUP SPR
Retail SPR SPR SUP SPR SPR SPR AU AU
School SPR SPR SPR SPR SPR SPR
Self-storage flicility SUP SPR
Sb0VDhM m laze SPR SPR". SUP SPR
Single-family Single-fbinily dwellim SPRM SPR
Ski center SPR
Stome facility,interior SPR SUP
Tavern SUP SUP SPR SUP
'TV or radio station SPR SPR SPR
Metainary clinic SPR SPR SPR SUP S[JP
DOTES:
(1) Large offices are prohibited in the Gurney Lane Office district.
(2) No residential uses aball be allowed less than 600 feet of Bay Road.See 1179-3.044B(2).
(3) All single-story uses and buildings setback beyond 40 feet require a special use permit
(4) Residential uses,including singlo-famity dwellings,duplexes or two-family dwelling,multiple-family dwellings,and townhouse are not allowed within 250 feet of
the centerline of Main Street Beyond 250 feet they are allowed with silo plan review_
179 Attachment 3:3 Sapp 71,aw 2020
QUEENSBURY CODE
(5) The manimum gross building resi&ntisl area(total unit squara footage)sball be 30%of the total building floor area of all other commercial buildings within the
ESC zoning district.See§178-3-040B(1)(b)[121.
179 Attachment 3.4 Sapp 71,3®n 2020
Full Environmental Assessment Form
Part l -Project and Setting
Instructions for Completing Part 1
Part 1 is to be completed by the applicant or project sponsor. Responses become part of the application for approval or funding,
are subject to public review,and may be subject to further verification.
Complete Part 1 based on information currently available. If additional research or investigation would be needed to fully respond to
any item,please answer as thoroughly as possible based on current information;indicate whether missing information does not exist,
or is not reasonably available to the sponsor;and,when possible,generally describe work or studies which would be necessary to
update or fully develop that information.
Applicants/sponsors must complete all items in Sections A&B. In Sections C,D&E,most items contain an initial question that
must be answered either"Yes"or"No". If the answer to the initial question is"Yes",complete the sub-questions that follow. If the
answer to the initial question is"No",proceed to the next question. Section F allows the project sponsor to identify and attach any
additional information. Section G requires the name and signature of the applicant or project sponsor to verify that the information
contained in Part lis accurate and complete.
A.Project and Applicant/Sponsor Information.
Name of Action or Project:
NEIGHBORHOOD RESIDENTIAL-DAY-CARE ZONING AMENDMENT
Project Location(describe,and attach a general location map):
TOWN-WIDE IN THE NR ZONING DISTRICT
Brief Description of Proposed Action(include purpose or need):
THE PROPOSAL IS TO ADD'DAY-CARE'AS AN ALLOWED USE BY SITE PLAN REVIEW IN THE NR ZONE IN THE TOWN OF QUEENSBURY
Name of Applicant/Sponsor: Telephone:
Queensbury Masonic Historical Society E-Mail:
Address:15 Burke Drive
City/PO:Queensbury State:NY Zip Code:12804
Project Contact(if not same as sponsor;give name and title/role): Telephone:518-668-2199
Matthew F Fuller,Esq./Meyer Fuller&Stockwell,PLLC E-Mail:
mfuller@meyerfuller.com
Address:
1557 State Route 9
City/PO: State: Zip Code:
Lake George New York 112845
Property Owner (if not same as sponsor): Telephone:
E-Mail:
Address:
City/PO: State: Zip Code:
Page 1 of 13
FEAF 2019
B.Government Approvals
B.Government Approvals,Funding,or Sponsorship. ("Funding"includes grants,loans,tax relief,and any other forms of financial
assistance.)
Government Entity If Yes:Identify Agency and Approval(s) Application Date
Required (Actual or projected)
a.City Counsel,Town Board, ®Yes❑No Town Board,Town of Queensbury
or Village Board of Trustees
b.City,Town or Village ❑Yes❑No
Planning Board or Commission
c.City,Town or ❑Yes❑No
Village Zoning Board of Appeals
d.Other local agencies ❑Yes❑No
e.County agencies ®Yes❑No Warren County Planning
f.Regional agencies ❑Yes❑No
g.State agencies ❑Yes❑No
h.Federal agencies ❑Yes❑No
i. Coastal Resources.
i. Is the project site within a Coastal Area,or the waterfront area of a Designated Inland Waterway? ❑YesmNo
U. Is the project site located in a community with an approved Local Waterfront Revitalization Program? ❑Yes®No
iii. Is the project site within a Coastal Erosion Hazard Area? ❑Yes®No
C..Planning and Zoning
C.I.Planning and zoning actions.
Will administrative or legislative adoption,or amendment of a plan,local law,ordinance,rule or regulation be the ®Yes❑No
only approval(s)which must be granted to enable the proposed action to proceed?
• If Yes,complete sections C,F and G.
• If No,proceed to question C.2 and complete all remaining sections and questions in Part 1
C.2.Adopted land use plans.
a.Do any municipally-adopted (city,town,village or county)comprehensive land use plan(s)include the site ®Yes❑No
where the proposed action would be located?
If Yes,does the comprehensive plan include specific recommendations for the site where the proposed action ❑Yes®No
would be located?
b.Is the site of the proposed action within any local or regional special planning district(for example:Greenway; ❑YesmNo
Brownfield Opportunity Area(BOA);designated State or Federal heritage area;watershed management plan;
or other?)
If Yes,identify the plan(s):
c. Is the proposed action located wholly or partially within an area listed in an adopted municipal open space plan, ❑YesmNo
or an adopted municipal farmland protection plan?
If Yes,identify the plan(s):
Page 2 of 13
C.3. Zoning
a. Is the site of the proposed action located in a municipality with an adopted zoning law or ordinance. ®Yes❑No
If Yes,what is the zoning classification(s)including any applicable overlay district?
NEIGHBORHOOD RESIDENTIAL-NR
b. Is the use permitted or allowed by a special or conditional use permit? ❑Yes®No
c.Is a zoning change requested as part of the proposed action? ®Yes❑No
If Yes,
i. What is the proposed new zoning for the site? NR BUT ALLOW DAY-CARE IN THE NR ZONE
CA.Existing community services.
a.In what school district is the project site located?QUEENSBURY
b.What police or other public protection forces serve the project site?
WARREN COUNTY SHERIFF,NYS TROOPERS
c.Which fire protection and emergency medical services serve the project site?
LOCAL EMS AND FIRE
d.What parks serve the project site?
NA
D.Project Details
D.1.Proposed and Potential Development
a.What is the general nature of the proposed action(e.g.,residential,industrial,commercial,recreational;if mixed,include all
components)?COMMERCIAL, RESIDENTIAL
b.a.Total acreage of the site of the proposed action? acres
b.Total acreage to be physically disturbed? acres
c.Total acreage(project site and any contiguous properties)owned
or controlled by the applicant or project sponsor? acres
c.Is the proposed action an expansion of an existing project or use? ❑Yes❑No
i. If Yes,what is the approximate percentage of the proposed expansion and identify the units(e.g.,acres,miles,housing units,
square feet)? % Units:
d.Is the proposed action a subdivision,or does it include a subdivision? ❑Yes❑No
If Yes,
i. Purpose or type of subdivision?(e.g.,residential,industrial,commercial;if mixed,specify types)
ii. Is a cluster/conservation layout proposed? ❑Yes❑No
iii. Number of lots proposed?
iv.Minimum and maximum proposed lot sizes? Minimum Maximum
e.Will the proposed action be constructed in multiple phases? ❑Yes❑No
L If No,anticipated period of construction: months
H. If Yes:
• Total number of phases anticipated
• Anticipated commencement date of phase 1 (including demolition) month year
• Anticipated completion date of final phase month -year
• Generally describe connections or relationships among phases,including any contingencies where progress of one phase may
determine timing or duration of future phases:
Page 3 of 13
f.Does the project include new residential uses? ❑Yes❑No
If Yes,show numbers of units proposed.
One Family Two Family Three Family Multiple Family Lftbur or more
Initial Phase
At completion
of all phases
g.Does the proposed action include new non-residential construction(including expansions)? ❑Yes❑No
If Yes,
f.Total number of structures
ii.Dimensions(in feet)of largest proposed structure: height; width; and length
iff. Approximate extent of building space to be heated or cooled: square feet
h.Does the proposed action include construction or other activities that will result in the impoundment of any ❑Yes❑No
liquids,such as creation of a water supply,reservoir,pond,lake,waste lagoon or other storage?
If Yes,
f. Purpose of the impoundment:
if. If a water impoundment,the principal source of the water: ❑ Ground water❑Surface water streams ❑Other specify:
iff. If other than water,identify the type of impounded/contained liquids and their source.
iv. Approximate size of the proposed impoundment. Volume: million gallons;surface area: acres
v.Dimensions of the proposed dam or impounding structure: height; length
vi. Construction method/materials for the proposed dam or impounding structure(e.g.,earth fill,rock,wood,concrete):
D.2. Project Operations
a.Does the proposed action include any excavation,mining,or dredging,during construction,operations,or both? ❑Yes❑No
(Not including general site preparation,grading or installation of utilities or foundations where all excavated
materials will remain onsite)
If Yes:
i.What is the purpose of the excavation or dredging?
ff. How much material(including rock,earth,sediments,etc.)is proposed to be removed from the site?
• Volume(specify tons or cubic yards):
• Over what duration of time?
iii. Describe nature and characteristics of materials to be excavated or dredged,and plans to use,manage or dispose of them.
iv. Will there be onsite dewatering or processing of excavated materials? ❑Yes❑No
If yes,describe.
v. What is the total area to be dredged or excavated? acres
vi. What is the maximum area to be worked at any one time? acres
vii. What would be the maximum depth of excavation or dredging? feet
viii. Will the excavation require blasting? ❑Yes❑No
ix. Summarize site reclamation goals and plan:
b.Would the proposed action cause or result in alteration of,increase or decrease in size of,or encroachment ❑Yes❑No
into any existing wetland,waterbody,shoreline,beach or adjacent area?
If Yes:
i. Identify the wetland or waterbody which would be affected(by name,water index number,wetland map number or geographic
description):
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H. Describe how the proposed action would affect that waterbody or wetland,e.g.excavation,fill,placement of structures,or
alteration of channels,banks and shorelines. Indicate extent of activities,alterations and additions in square feet or acres:
X.Will the proposed action cause or result in disturbance to bottom sediments? ❑Yes❑No
If Yes,describe:
iv. Will the proposed action cause or result in the destruction or removal of aquatic vegetation? ❑Yes❑No
If Yes:
• acres of aquatic vegetation proposed to be removed:
• expected acreage of aquatic vegetation remaining after project completion:
• purpose of proposed removal(e.g.beach clearing,invasive species control,boat access):
• proposed method of plant removal:
• if chemical/herbicide treatment will be used,specify product(s):
v. Describe any proposed reclamation/mitigation following disturbance:
c.Will the proposed action use,or create a new demand for water? ❑Yes❑No
If Yes:
i. Total anticipated water usage/demand per day: gallons/day
ii. Will the proposed action obtain water from an existing public water supply? ❑Yes❑No
If Yes:
• Name of district or service area:
• Does the existing public water supply have capacity to serve the proposal? ❑Yes❑No
• Is the project site in the existing district? ❑Yes❑No
• Is expansion of the district needed? ❑Yes❑No
• Do existing lines serve the project site? ❑Yes❑No
iii. Will line extension within an existing district be necessary to supply the project? ❑Yes❑No
If Yes:
• Describe extensions or capacity expansions proposed to serve this project:
• Source(s)of supply for the district:
iv.Is a new water supply district or service area proposed to be formed to serve the project site? ❑Yes❑No
If,Yes:
• Applicant/sponsor for new district:
• Date application submitted or anticipated:
• Proposed source(s)of supply for new district:
v. If a public water supply will not be used,describe plans to provide water supply for the project:
vi.If water supply will be from wells(public or private),what is the maximum pumping capacity: gallons/minute.
d.Will the proposed action generate liquid wastes? ❑Yes❑No
If Yes:
i. Total anticipated liquid waste generation per day: gallons/day
ii.Nature of liquid wastes to be generated(e.g.,sanitary wastewater,industrial;if combination,describe all components and
approximate volumes or proportions of each):
M. Will the proposed action use any existing public wastewater treatment facilities? ❑Yes❑No
If Yes:
• Name of wastewater treatment plant to be used:
• Name of district:
• Does the existing wastewater treatment plant have capacity to serve the project? ❑Yes❑No
• Is the project site in the existing district? ❑Yes❑No
• Is expansion of the district needed? ❑Yes❑No
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• Do existing sewer lines serve the project site? []Yes[:]No
• Will a line extension within an existing district be necessary to serve the project? ❑Yes❑No
If Yes:
• Describe extensions or capacity expansions.proposed to serve this project:
iv. Will a new wastewater(sewage)treatment district be formed to serve the project site? ❑Yes❑No
If Yes:
• Applicant/sponsor for new district:
• Date application submitted or anticipated:
• What is the receiving water for the wastewater discharge?
v. If public facilities will not be used,describe plans to provide wastewater treatment for the project,including specifying proposed
receiving water(name and classification if surface discharge or describe subsurface disposal plans):
vi. Describe any plans or designs to capture,recycle or reuse liquid waste:
e.Will the proposed action disturb more than one acre and create stormwater runoff,either from new point ❑Yes❑No
sources(i.e.ditches,pipes,swales,curbs,gutters or other concentrated flows of stormwater)or non-point
source(i.e.sheet flow)during construction or post construction?
If Yes:
i. How much impervious surface will the project create in relation to total size of project parcel?
Square feet or acres(impervious surface)
Square feet or acres(parcel size)
ii. Describe types of new point sources.
iii. Where will the stormwater runoff be directed(i.e.on-site stormwater management facility/structures,adjacent properties,
groundwater,on-site surface water or off-site surface waters)?
• If to surface waters,identify receiving water bodies or wetlands:
• Will stormwater runoff flow to adjacent properties? ❑Yes❑No
iv. Does the proposed plan minimize impervious surfaces,use pervious materials or collect and re-use stormwater? ❑Yes❑No
f. Does the proposed action include;or will it use on-site,one or more sources of air emissions,including fuel ❑Yes❑No
combustion,waste incineration,or other processes or operations?
If Yes,identify:
i.Mobile sources during project operations(e.g.,heavy equipment,fleet or delivery vehicles)
ii. Stationary sources during construction(e.g.,power generation,structural heating,batch plant,crushers)
iii. Stationary sources during operations(e.g.,process emissions,large boilers,electric generation)
g.Will any air emission sources named in D.2.f(above),require a NY State Air Registration,Air Facility Permit, ❑Yes❑No
or Federal Clean Air Act Title IV or Title V Permit?
If Yes:
i. Is the project site located in an Air quality non-attainment area? (Area routinely or periodically fails to meet ❑Yes❑No
ambient air quality standards for all or some parts of the year)
U In addition to emissions as calculated in the application,the project will generate:
• Tons/year(short tons)of Carbon Dioxide(CO2)
• Tons/year(short tons)of Nitrous Oxide(N20)
• Tons/year(short tons)of Perfluorocarbons(PFCs)
• Tons/year(short tons)of Sulfur Hexafluoride(SF6)
• Tons/year(short tons)of Carbon Dioxide equivalent of Hydroflourocarbons(HFCs)
• Tons/year(short tons)of Hazardous Air Pollutants(HAPs)
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h.Will the proposed action generate or emit methane(including,but not limited to,sewage treatment plants, ❑Yes❑No
landfills,composting facilities)?
If Yes:
i.Estimate methane generation in tons/year(metric):
U.Describe any methane capture,control or elimination measures included in project design(e.g.,combustion to generate heat or
electricity,flaring):
i.Will the proposed action result in the release of air pollutants from open-air operations or processes,such as ❑Yes❑No
quarry or landfill operations?
If Yes:Describe operations and nature of emissions(e.g.,diesel exhaust,rock particulates/dust):
j.Will the proposed action result in a substantial increase in traffic above present levels or generate substantial ❑Yes❑No
new demand for transportation facilities or services?
If Yes:
i. When is the peak traffic expected(Check all that apply): ❑Morning ❑Evening ❑Weekend
❑Randomly between hours of to
ii. For commercial activities only,projected number of truck trips/day and type(e.g.,semi trailers and dump trucks):
iii. Parking spaces: Existing Proposed Net increase/decrease
iv.Does the proposed action include any shared use parking? ❑Yes❑No
v If the proposed action includes any modification of existing roads,creation of new roads or change in existing access,describe:
vi. Are public/private transportation service(s)or facilities available within'/2 mile of the proposed site? ❑Yes❑No
vii Will the proposed action include access to public transportation or accommodations for use of hybrid,electric ❑Yes❑No
or other alternative fueled vehicles?
viii.Will the proposed action include plans for pedestrian or bicycle accommodations for connections to existing ❑Yes❑No
pedestrian or bicycle routes?
k.Will the proposed action(for commercial or industrial projects only)generate new or additional demand ❑Yes❑No
for energy?
If Yes:
i. Estimate annual electricity demand during operation of the proposed action:
ii. Anticipated sources/suppliers of electricity for the project(e.g.,on-site combustion,on-site renewable,via grid/local utility,or
other):
iii. Will the proposed action require a new,or an upgrade,to an existing substation? ❑Yes❑No
1.Hours of operation. Answer all items which apply.
i. During Construction: ii. During Operations:
• Monday-Friday: • Monday-Friday:
• Saturday: • Saturday:
• Sunday: • Sunday:
• Holidays: • Holidays:
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m.Will the proposed action produce noise that will exceed existing ambient noise levels during construction, ❑Yes❑No
operation,or both?
If yes:
i. Provide details including sources,time of day and duration:
ii. Will the proposed action remove existing natural barriers that could act as a noise barrier or screen? ❑Yes❑No
Describe:
n.Will the proposed action have outdoor lighting? ❑Yes❑No
If yes:
i. Describe source(s),location(s),height of fixture(s),direction/aim,and proximity to nearest occupied structures:
H. Will proposed action remove existing natural barriers that could act as a light barrier or screen? ❑Yes❑No
Describe:
o.Does the proposed action have the potential to produce odors for more than one hour per day? ❑Yes❑No
If Yes,describe possible sources,potential frequency and duration of odor emissions,and proximity to nearest
occupied structures:
p.Will the proposed action include any bulk storage of petroleum(combined capacity of over 1,100 gallons) ❑Yes[]No
or chemical products 185 gallons in above ground storage or any amount in underground storage?
If Yes:
i.Product(s)to be stored
ii. Volume(s) per unit time (e.g.,month,year)
iii. Generally,describe the proposed storage facilities:
q.Will the proposed action(commercial,industrial and recreational projects only)use pesticides(i.e.,herbicides, ❑Yes [-]No
insecticides)during construction or operation?
If Yes:
i.Describe proposed treatment(s):
H. Will the proposed action use Integrated Pest Management Practices? ❑ Yes ❑No
r.Will the proposed action(commercial or industrial projects only)involve or require the management or disposal ❑ Yes ❑No
of solid waste(excluding hazardous materials)?
If Yes:
i. Describe any solid waste(s)to be generated during construction or operation of the facility:
• Construction: tons per (unit of time)
• Operation: tons per (unit of time)
ii.Describe any proposals for on-site minimization,recycling or reuse of materials to avoid disposal as solid waste:
• Construction:
• Operation:
iii.Proposed disposal methods/facilities for solid waste generated on-site:
• Construction:
• Operation:
Page 8 of 13
s.Does the proposed action include construction or modification of a solid waste management facility? ❑Yes❑ No
If Yes:
i. Type of management or handling of waste proposed for the site(e.g.,recycling or transfer station,composting,landfill,or
other disposal activities):
ii. Anticipated rate of disposal/processing:
• Tons/month,if transfer or other non-combustion/thermal treatment,or
• Tons/hour,if combustion or thermal treatment
iii. If landfill,anticipated site life: years
t.Will the proposed action at the site involve the commercial generation,treatment,storage,or disposal of hazardous❑Yes❑No
waste?
If Yes:
i.Name(s)of all hazardous wastes or constituents to be generated,handled or managed at facility:
H. Generally describe processes or activities involving hazardous wastes or constituents:
iii.Specify amount to be handled or generated tons/month
iv.Describe any proposals for on-site minimization,recycling or reuse of hazardous constituents:
v. Will any hazardous wastes be disposed at an existing offsite hazardous waste facility? ❑Yes❑No
If Yes:provide name and location of facility:
If No: describe proposed management of any hazardous wastes which will not be sent to a hazardous waste facility:
E.Site and Setting of Proposed Action
E.I.Land uses on and surrounding the project site
a.Existing land uses.
i. Check all uses that occur on,adjoining and near the project site.
❑ Urban ❑ Industrial ® Commercial ❑ Residential(suburban) ❑Rural(non-farm)
❑ Forest ❑ Agriculture ❑ Aquatic ❑ Other(specify):
ii. If mix of uses,generally describe:
b.Land uses and covertypes on the project site.
Land use or Current Acreage After Change
Covertype Acreage Project Completion (Acres+/-)
• Roads,buildings,and other paved or impervious
surfaces
• Forested
• Meadows,grasslands or brushlands(non-
agricultural,including abandoned agricultural)
• Agricultural
(includes active orchards,field,greenhouse etc.)
• Surface water features
(lakes,ponds,streams,rivers,etc.)
• Wetlands(freshwater or tidal)
• Non-vegetated(bare rock,earth or fill)
• Other
Describe:
Page 9 of 13
c.Is the project site presently used by members of the community for public recreation? ❑Yes❑No
i.If Yes:explain:
d.Are there any facilities serving children,the elderly,people with disabilities(e.g.,schools,hospitals,licensed ❑Yes❑No
day care centers,or group homes)within 1500 feet of the project site?
If Yes,
i. Identify Facilities:
QUEENSBURY SCHOOL
e.Does the project site contain an existing dam? ❑Yes❑No
If Yes:
i.Dimensions of the dam and impoundment:
• Dam height: feet
• Dam length: feet
• Surface area: acres
• Volume impounded: gallons OR acre-feet
ii.Dam's existing hazard classification:
W. Provide date and summarize results of last inspection:
f.Has the project site ever been used as a municipal,commercial or industrial solid waste management facility, ❑Yes❑No
or does the project site adjoin property which is now,or was at one time,used as a solid waste management facility?
If Yes:
i.Has the facility been formally closed? ❑Yes❑No
• If yes,cite sources/documentation:
ii.Describe the location of the project site relative to the boundaries of the solid waste management facility:
iff. Describe any development constraints due to the prior solid waste activities:
g.Have hazardous wastes been generated,treated and/or disposed of at the site,or does the project site adjoin ❑Yes❑No
property which is now or was at one time used to commercially treat,store and/or dispose of hazardous waste?
If Yes:
i. Describe waste(s)handled and waste management activities,including approximate time when activities occurred:
h. Potential contamination history. Has there been a reported spill at the proposed project site,or have any ❑Yes❑No
remedial actions been conducted at or adjacent to the proposed site?
If Yes:
i. Is any portion of the site listed on the NYSDEC Spills Incidents database or Environmental Site ❑Yes❑No
Remediation database? Check all that apply:
❑ Yes—Spills Incidents database Provide DEC ID number(s):
❑ Yes—Environmental Site Remediation database Provide DEC ID number(s):
❑ Neither database
ii. If site has been subject of RCRA corrective activities,describe control measures:
iii. Is the project within 2000 feet of any site in the NYSDEC Environmental Site Remediation database? ❑Yes❑No
If yes,provide DEC ID number(s):
iv. If yes to(i),(ii)or(iii)above,describe current status of site(s):
Page 10 of 13
v. Is the project site subject to an institutional control limiting property uses? ❑Yes[--]No
• If yes,DEC site ID number:
• Describe the type of institutional control(e.g.,deed restriction or easement):
• Describe any use limitations:
• Describe any engineering controls:
• Will the project affect the institutional or engineering controls in place? ❑Yes❑No
• Explain:
E.2. Natural Resources On or Near Project Site
a.What is the average depth to bedrock on the project site? NA feet
b.Are there bedrock outcroppings on the project site? ❑Yes❑No
If Yes,what proportion of the site is comprised of bedrock outcroppings? %
c.Predominant soil type(s)present on project site: %
d.What is the average depth to the water table on the project site? Average: feet
e.Drainage status of project site soils:❑Well Drained: %of site
❑ Moderately Well Drained: %of site
❑ Poorly Drained %of site
f.Approximate proportion of proposed action site with slopes: ❑ 0-10%: %of site
❑ 10-15%: %of site
❑ 15%or greater: %of site
g.Are there any unique geologic features on the project site? ❑Yes❑No
If Yes,describe:
h. Surface water features.
i. Does any portion of the project site contain wetlands or other waterbodies(including streams,rivers, ❑Yes❑No
ponds or lakes)?
H. Do any wetlands or other waterbodies adjoin the project site? ❑Yes❑No
If Yes to either i or ii,continue. If No,skip to E.2.i.
HL Are any of the wetlands or waterbodies within or adjoining the project site regulated by any federal, ❑Yes❑No
state or local agency?
iv. For each identified regulated wetland and waterbody on the project site,provide the following information:
• Streams: Name Classification
• Lakes or Ponds: Name Classification
• Wetlands: Name Approximate Size
• Wetland No.(if regulated by DEC)
v. Are any of the above water bodies listed in the most recent compilation of NYS water quality-impaired ❑Yes❑(`lo
waterbodies?
If yes,name of impaired water body/bodies and basis for listing as impaired:
i.Is the project site in a designated Floodway? []Yes[]No
j.Is the project site in the 100-year Floodplain? ❑Yes❑No
k.Is the project site in the 500-year Floodplain? ❑Yes❑No
1.Is the project site located over,or immediately adjoining,a primary,principal or sole source aquifer? ❑Yes❑No
If Yes:
i.Name of aquifer:
Page 11 of 13
in. Identify the predominant wildlife species that occupy or use the project site:
n.Does the project site contain a designated significant natural community? ❑Yes❑No
If Yes:
i.Describe the habitat/community(composition,function,and basis for designation):
ii. Source(s)of description or evaluation:
W. Extent of community/habitat:
• Currently: acres
• Following completion of project as proposed: acres
• Gain or loss(indicate+or-): acres
o.Does project site contain any species of plant or animal that is listed by the federal government or NYS as ❑Yes❑No
endangered or threatened,or does it contain any areas identified as habitat for an endangered or threatened species?
If Yes:
i. Species and listing(endangered or threatened):
p. Does the project site contain any species of plant or animal that is listed by NYS as rare,or as a species of ❑Yes❑No
special concern?
If Yes:
i. Species and listing:
q.Is the project site or adjoining area currently used for hunting,trapping,fishing or shell fishing? ❑Yes❑No
If yes,give a brief description of how the proposed action may affect that use:
E.3. Designated Public Resources On or Near Project Site
a.Is the project site,or any portion of it,located in a designated agricultural district certified pursuant to ❑Yes❑No
Agriculture and Markets Law,Article 25-AA,Section 303 and 304?
If Yes, provide county plus district name/number:
b.Are agricultural lands consisting of highly productive soils present? ❑Yes❑No
L If Yes:acreage(s)on project site?
H. Source(s)of soil rating(s):
c. Does the project site contain all or part of,or is it substantially contiguous to,a registered National ❑Yes❑No
Natural Landmark?
If Yes:
i. Nature of the natural landmark: ❑Biological Community ❑ Geological Feature
H.Provide brief description of landmark,including values behind designation and approximate size/extent:
d.Is the project site located in or does it adjoin a state listed Critical Environmental Area? ❑Yes❑No
If Yes:
i. CEA name:
H.Basis for designation:
iii. Designating agency and date:
Page 12 of 13
b
w
e.Does the project site contain,or is it substantially contiguous to,a building,archaeological site,or district ❑YesONo
which is listed on the National or State Register of Historic Places,or that has been determined by the Commissioner of the NYS
Office of Parks,Recreation and Historic Preservation to be eligible for listing on the State Register of Historic Places?
If Yes:
i.Nature of historic/archaeological resource: []Archaeological Site ❑Historic Building or District
ii.Name:
W.Brief description of attributes on which listing is based:
f.Is the project site,or any portion of it,located in or adjacent to an area designated as sensitive for ❑Yes®No
archaeological sites on the NY State Historic Preservation Office(SHPO)archaeological site inventory?
g.Have additional archaeological or historic site(s)or resources been identified on the project site? ❑Yes®No
If Yes:
i.Describe possible resource(s):
ii. Basis for identification:
h.Is the project site within fives miles of any officially designated and publicly accessible federal,state,or local ❑Yes®No
scenic or aesthetic resource?
If Yes:_
i.Identify resource:
ii.Nature of,or basis for,designation(e.g.,established highway overlook,state or local park,state historic trail or scenic byway,
etc.):
M.Distance between project and resource: miles.
i. Is the project site located within a designated river corridor under the Wild,Scenic and Recreational Rivers ❑Yes®No
Program 6 NYCRR 666?
If Yes:
i.Identify the name of the river and its designation:
ii.Is the activity consistent with development restrictions contained in 6NYCRR Part 666? ❑Yes®No
F.Additional Information
Attach any additional information which may be needed to clarify your project.
If you have identified any adverse impacts which could be associated with your proposal,please describe those impacts plus any
measures which you propose to avoid or minimize them.
G. Verification
I certify that the information provided is true to the best of mIT',
owledge.
Applicant/SponsorName �� Date 5
Signature Title
Sign �
CQ
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