Application TOWN OF QUEENSBURY
DEPARTMENT OF COMMUNITY DEVELOPMENT
SITE PLAN REVIEW APPLICATION
APPLICATION NO.
A , i1 -9
I . APPLICANT: - M&&1
ADDRESS :
AS
Phone # : Home
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Phone # : Work
APPLICANT'S AGENT:
ADDRESS:
Phone # : Home
Phone #: Work PROPERTY OWNER: 4 ,
ADDRESS :
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Phone # : Home
Phone # : Work /
ry / ,, /'
PROPERTY LOCATION: �J � ( &Aei(J /( Ak C • �/
TAX MAP NO.
I' rr�
ZONE CLASSIFICATION: ��,,,y
DESCRIPTION Off' PR JECT: OIA4 A{'!!�1 10A
DIRECTIONS TO THE PROJECT (for Board members & Staff to locate
project for site visit) :,
RA�R
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II . SITE DEVELOPMENT DATA
AREA OF PARCEL • ,31K acres = sq. ft.
MAXIMUM SIZE BUILDING ALLOWED: sq. ft.
DISPOSITION OF PARCEL:
Existing
Building area sq. ft. = % of parcel
Paved area sq. ft. = % of parcel
(including walks)
Green area sq. ft. = % of parcel
Proposed
Building area sq. ft. = % of parcel
. Paved area sq. ft. = % of parcel
(including walks )
Green area sq. ft. = % of parcel
Building Setbacks
Existing ./P�Ir""000posed Required
Front Yard OVY �
Front ( if corner)
Side Yard ( 1)
Side Yard (2 )
Rear Yard
Rear Yard (2 )
Shoreline
Width
Depth
ACCESS (check where applicable)
Town Highway County State
LENGTH OF FRONTAGE
NUMBER OF PARKING SPACES: Existing _ Proposed
TOWN WATER: /� Yes No
TOWN SEWER: Yes No
Any previous Planning or Zoning Board determinations regarding
this property? A0
Present Use of Property: (QiAotfa,Proposed Use of Property: rnhdht� l//1�Y6�y
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APPLICANT PLEASE READ AND SIGN BELOW
A COMPLETE- APPLICATION IS NECESSARY FOR PLACEMENT ON THE
PLANNING BOARD AGENDA.
The Planning Office requires :
10 copies of your site plan application, maps, supporting
documentation - 1 original and 9 copies.
e ee an survey plat.
The fee for site plan review is $25.00.
Applications may be referred to the Town consulting engineer
for review of septic design, storm drainage, etc. The applicant is
required to pay for the costs associated with this review. The
hourly rate charge for the engineering review will be charged
directly to the applicant. Fees for engineering review will not
exceed $1, 000 . 00 without notification to the applicant.
Other permits may be required for construction or alteration
subsequent to approval by the Planning Board. It is the
applicant' s responsibility to obtain these.
I, the undersigned, have thoroughly read and understand the
instructions for submission, agree to the submission requirements
and completed the checklist . Furthermore, it is the practice of
the Department of Community Development to have a designated
stenographer tape record the proceedings of the meeting resulting
from application review, and that minutes transcribed from those
tapes constitute the official record of all proceedings . If there
is a discrepancy between such record and the handwritten minutes
• taken by the designated stenographer, the handwritten minutes shall
be deemed the official record.
I HAVE READ AND AGREE TO THE ABOVE STATEMENT: c+
Applicant' s Signature Date Z 1
Applicant' s Agent Signature Date
(if Authorisation to Act as
Agent form has been signed)
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14:164(9195)_Text 12
PROJECT I.D.NUMBER 61720 -- SEQR
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 spersor)
1. APPLICANT/SPONSOR 2. PROJECT NAME
3. PROJECT LOCATION:
Municipality County
4. PRECISE LOCATION(Street address and road Intersect) ns,prom) nI landmarks.ere.or provids-nap) -
5. IS PROPOSED ACTION: nn
❑New ❑S-cansion U!ACclticlucn!at:e!akan
6. DESCRIES FRCJECT SFIE-v.
0
7. AMCUNT CF LAND AFFECTED:
Initially acres L'Illmataq acres
S. WIILL/L PROPOSED ACTION COMPLY WITH EXISTING ZCNING OR OTHER EXIST =,EXISTING LAND USE FEET,RIC7LONS7
U?.Yes ❑No it No,describe bristly
9. WHAT 15 PRESENT LAND USE IN VICINITY OF PROJEC7.7
rw
❑Residential ❑Industrial yacommercial ❑Agriculture ❑P3rklFc.2stlCpen space ❑Other
Descrlbe:k&t � X /��7�/� �p
/�I , J(IJC.�t6b
10. DOES ACTION INVOLVE A PERMIT APPROVAL.OR FUNDING,NOW OR ULTIMATELY FFCM AAY CT HER GOVERNMENTAL AGENCY(FEDFRA.t.
STATE OR LOCAu4
❑Yes 4Np It yes,Ilst agency(s)and pennit/approvals
11. DOES ANY ASPEST CF 7HE AC,ICH HAVE A CUFFENTLY VALID PERMIT GRAF=FCVAL'.
❑Yes $140 II?es, list agent/ oars ant cerit'accroval
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12. AS A RESULT 0 PROPOSED ACTION WILL E(IS iNG PERMITIAPPROVAL FECUIFE!ACC1FiCA'CN7
❑Yes No
I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE E.EET OF MY KNOWLEDGE
Appticantlsponsor ame: Oats: '?
Signature: c z
If the action is in the Coastal Area, and you are a state agency, complete the
Coastal Assessment Form before proceeding with his assessment
OVER
PART It—ENVIRONMENTAL ASSESSMENT (To be contp!eted by Agency)
A. DOES ACTION EY EED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.4? It yes,coordinate the review process no use cite FULL EAF.
❑Yes Na
S. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR•PART 617.6? If No.a negative asclaration
may be superseded by another involved agency.
C. C LD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING(Answers may be handwritten• it legible)
t. Existing air quality, surface or groundwater quality or quantity, noise levels, existing traffic patterns, solid waste production or disposal,
potential for erosion, drainage at flooding problems? Explain briefly:
1
C2 Aesthetic,agricultural.archaeological,historic,or other natural or cultural resources;or community Or neignbomaod character?Explain brieilyo
CO. Vegetation or fauna,fish,shellfish or wildlife species, significant habitats,ar threatened or endangered species?Explain briefly:
• Cit. A community's existing plans or goals as officially adopted,or a change in use or intensity at use of land or other natural resources?Explain briefly
CS. _rcwtn, su:secuent deveicdmem. :(:e!ztec=wines iikery :c :a :•tcucto: :`e;roc--sec ac:ign? E<c::;n -.:ell.,.
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,,.. _:pg ._..... ...... term. camma:.as.:: ...._. :..._._ -c: :c:......-_ '.: .^=. •: - --,
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C7. Other impacts gncfudfng oranges in use of either quantity Or type at energy)? Explain briefly.
0. WILL,mE PROJEC NAVE AN IMPAC. ON THE ENVIRONMENTAL CHARAC,cJSTiCS`MHAT CAUSM THE SABLISHMENT OF A CFA?
❑Yes 6�No
E IS THERE OR IS THERE LIKELY TO 8E CONTROVERSY RELATED TO POTENTIAL ADVERSE-ENVIRCNMENTAL IMPACS?
❑Yes LSLNo If Yes,explain briefly
PART III—DETERMINATION OF SIGNIFICANCE (To be completed by agency)
INSTRUCTIONS: For each adverse effect identified above,determine whether it is substantial,!ar;e,imperant cr otherwise significant.
Each effect should be assessed in cdnnecdcri with its (a) setting (I.e. urcan or rurafl; (c) ;re:acility of -:taring; (c) durai;cr.; (ci
irreversibility;(et geograpnic score; and (f) magnitude. If necessary, add attachments or reference sucoering materials. 2nsure :rat
exotanaticns contain sufficient cetaii to sne•w !hat all relevant adverse impacts nave :den (c_nni(ed acc aceduately accressac. 'f
cues;cn D of Part 11 was checked yes, :he catermmation arc significance must evaluate:`e :_.xnual i.T.:ac: :f the prcccsa_c a_.._-
Cn the environmental characteristics of :re CE.4. 1
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.
Cl 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:
i
Name or Leaa Age
, Dpe rrt.r �flGiAiG
Print bt Type N me of AOOonfmle Officer n Lea A mcY - iat o<atlaanfale Olncer
15slinaufte or KnOCAS1014, t r n ea aenCr— at P e,arer(le cullawt tram relponuete onrcvl
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Dace
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