Application 8/20/02 Site Plan Review
General Information
Application No. (Office Use Only)
Project Location:
Tax Map ID: 9f.do /-
Zone Classification: !fG ir/ f
Compliance with Zoning Ordinance Section:
Detailed Description of Project:
(include current& Proposed use): Tn e I(_(l(eoe exte-e-0•^ 1-1744n o
Modification to existing Site Plan, Yes: No:
(If so,indicate Site Plan No. & approval date)
Square Footage of proposed structure:
Applicant: Nemer• r,-4-
Address: 3a.3 alk.Ker k
ome Phone:
Work Phone/ Fax: 79f-zK 34 - 7-7X-el6G
Applicant's Agent: Gnn k A�m4 jn g
Address: -5p"n yes 146.,i�-
Home Phone:
Work Phone/ Fax: pp 11
Property Owner: nhel-f Ir 41�o At I nef
Address: Sara n.•s eA')V-
Home Phone:
Work Phone/Fax:
Directions to Site:
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8/20/02 Site Plan Review
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Site Development Data
Area/Type Existing sq. ft. Proposed Addition Total sq. ft.
sq. ft.
A. Building Footprint
B. Detached Garage
C. Accessory Structure(s)
D. Paved, gravel or other
hard surfaced areas 14,9, ,'d
E. Porches/Decks
F. Other
Total Non-Permeable
Sum A through F 17Nd /7�fo
Parcel Area
ercent Non-Permeable 3a a
otal Non-Permeable/Parcel Area 3OZ
Setback Requirements
Required Existing Proposed
Front (1) 0 i
Front (2)
Shoreline
Side Yard(1)
Side Yard(2)
Rear Yard(1) i
Rear Yard(2)
Buffer/Travel Corridor
Height
Permeability
gn Setback
No. of Parking Spaces D
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8/20/02 Site Plan Review
6ecklist—please prepare a map depicting existing and proposed conditions. Failure to complete the following
ecklist or include all required information may result in a determination of incompleteness and a delay in the
processing of your application
PR NA WR Address 9#0 Item
GENERAL
f A.Title,name, address of applicant&person responsible for preparation of drawing
B.North arrow,Tax Map ID, date prepared and scale(minimum 1 in.=40 ft.)
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.
/ 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
V/ 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
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
material e. .,gavel,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
E. Signage: Location, size,type, design and setback
F. Waiver Request: provide letter with application requesting any waivers
G. Commercial / Industrial Development requires submission of a Landscaping Plan, Stormwater
Mana ement Plan, Grading Plan and a Lighting Plan
H. The Bd. may request other elements as considered necessary.
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 County officials.
Legend: PR—Provided; NA—Not Applicable; WR—Waiver Requested ID
•
TOWN OF QUEENSBURY
742 Bay Road, Queensbury, NY. 12804-5902
Town of Queensbury
Planning Board
Waiver Request
I hereby request that the Planning Board grant me a waiver from the
requirement for the submission of the following plans.
orStormwater Management Plan
a/'Grading Plan
e 'Lighting Plan
o/�Landscaping Plan
1
I acknowledge that these plans are required and I seek such waivers)
knowinglllyl and for/the following reasons:
A/of /hangt�� �srgn�rs
• A plicant Date
L:\Crcdg\lemplates\VVaiverReq8602.doc
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8/20/02 Site Plan Review
1416J IHNB}—Teltt It
PROJECT I.D.NUMBER 617.20 SEOR
Appendix C
State Environmental Duality Review
SHORT ENVIRONMENTAL ASSESSMENT FORM
For UNLISTED ACTIONS Only
PART I—PROJECT INFORMATION (To be completed by Applicant or Project sponsor)
1. APPUfANT ISPONSOR 2. PROJECT NAME
dip
Oct
3. PROJECT LOCATION:
Municipality y� FQL County /
4. PRECISE LOCATION(Street address and road Intensetims,prominent landmarks,etc.,or provide map)
5. IS PROPOSED ACTION: ,,./}
❑New ❑Expansion as ModRlcalbNaBMMbn
8. DESCRIBE PROJECT BRIEFLY:
7. AMOUNT OF LAND AFFECTED:
initially cres UUMutel ae
8. WILL POSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS?
Yu ❑No If No,descibe briefly
g. WHAT IS PRESENT LAND USE IN VICINITY OF
❑ReaWanual ❑Ind usWAl CJ Commercial ❑Agrlounure ❑ParWForest/Opan space ❑aIIN
Describr
10. DOES ACTION INVOLVE A PERMIT APPROVAL OR FUNDING,NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY(FEDERAL,
STATE OR LOCAL?��//
❑Yea Il3No If Yes,list agarcytN and permluappMels
11, DOES ANY AS OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL?
❑Yee No If yes,list agency name And P"Ithapprwal
12. AB A RESULT OF SEO ACTION WILL EXISTING PERMITIAPPROVAL REQUIRE MODIFICATION?
❑Yas P o
I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE //� ([
Applleant/s carat nama: j'pcX� Date: ..J� _et_ /
Signature:
It the act 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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8/20/02 Site Plan Review
• PART II—ENVIRONMENTAL ASSESSMENT(To be completed by Agency)
A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR PART 61TA? If yes,coordinate the revlew process and use the FULL EAF.
❑Yee ❑No
B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR,PARr 617.6? If No,a negarb"declaration
may be superseded by 9n0ther involved agency.
❑Yee Ohio
C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING:(Answers,may be handwritten.It legible)
Cl. Existing air quality, surface or groundwater qualihy or quantity, not" levels, existing traffic patlems, solid waste Production or disposal,
Potential for Moalon,drainage or flooding problems?Explain briefly.
C2. Aesthetic agricultural.archaeological,historic,or other natural or cultural resources;or community of neighborhood characlel.Explain briefly:
C3. Vegetation or fauna.fish,shellfish or wildlife species,significant habitats,or threatened or endangered species?Explain briefly:
Ca. A community's existing plane or goals as officially adopted,or a change in use or Intensity of use of land or other natural resources?Explain briefly
CS. Growth,subsequent d sk pmant,or related activities llxefy to lea Induced by the proposed action?Explain briefly.
C6. Lore term,short term,cumulative,or other effects not Identified In CI-057 Explain briefly. -
C7. Other Impacts(Including changes in use of either quantity or type of energy)?Explain briefly.
O. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CEA?
❑Yw ❑No
E 15 THERE,OR IS THERE LIKELY TO BE,CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS?
❑Yes ❑No If Yea,explain briefly
PART III—DETERMINATION OF SIGNIFICANCE(To be completed by Agency)
INSTRUCTIONS: For each adverse effect Identified above,determine whether It Is substantial,large,important or otherwise signikcant.
Each affect should be assessed in connection with Its(a) setting(i.e. urban or rurafY,(b) probability of mounting;(c)duration;(d)
Irrswrsiblihy;(a)geographic Scope,and(O magnitude.If necessary,add attachments or reference supporting materials.Ensure that
explanNlors contain sufficient detail to show that all relevant adverse Impacts have been Identified and adequately addressed. If
question O of Part it was checked yes,the determination and significance must evaluate the potential Impact of the proposed action
on the environmental characterietkS 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:
Name of LeadAgency
Print or Ty,pe Name of flxsocmibl.0111ker m L 7w;77 Tiffs ot Rex,camwbI*office,
,aNWM of ff.ponsible UlflC m L! IgMWre.1 P1.1's.,(If different ram'e';;m e a I[M
Dale
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8/20/02 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: e _ ,et,e,-
Designates: �gdk g.1-e
As agent regarding _Variance_Site Plan _Subdivision
For Tax Map No.: Section Block Lot
Deed Reference: _B9 _Page Date
l
SIGNATURE: (Owner) 4 A�!(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 the checklist.
SIGNATURE OF APPLICANT: -Date
SIGNATURE OF AGENT: -Date