Application F ,
17,m
• V l
TOWN 0_F Q UE
c_E vSBURf
COMMERCIAL, INDUSTRIIlAL, PROFESSIONAL OFFICE SITE PLAN REVIEW
APPLICATION NUMBER: rX q —q3 `
I . Applicant ' s :came : _D(XV% 8 c 5u7-4.Y)!oP aaY tPS
Street Address : -u Churcl} I.F,ne.
City, State , Zip: C�"eensbury � NI meo4
Telephone : (5f8)l43 314.3
2 . Agent ' s Name :
Street Address :
City, State, Zip :
_elephone :
3 . Owner ' s Name : DONXd :SuzC+nne. BC.Yne.S
street Address : vrc�� nne
City, State, Zip : �ueenSID r0 N IZ ELF
Telephone : ( Iti)193-3q `-f
4 . Property 'Location: lnc).tmo- Nit- and l-uzVXwe Roma
-
IN THE SPACE BELOW, draw an overview (site location) where Your
property is located. You ..^av d' h to __e c po=Lion of the :;wn _ -
Queensbury Road soar- for this . Show north arrow, strew-' cop--_-
(name them) and identify your property. s;ote : this map does --_
have to be drawn to scale .
f
Y
+ 19
5 . Description of .._w _. f__' ^e property • 54-e, mo.
5 . Tax Map Number : .ect_o.. . 121 Bloch:: 14 Lot:
7 . Zone Classificat:-.:!: MR5
8 . Is the lot in within 500 feet of a County or a Ste`
Right of Way or ParK, Municipal Boundary, or watershed draining any
County or State fa__ _ _ties , requiring review of the WARREN C•C11i+7'_
PLANNING BOARD: YES : NO:
I . APPLICANT' S PROPOSED ACTION: (Check where applicable)
New Site Charge of Use Site Change _Addition
Demolition Renovation
1 . Present Use of Property ( If vacant existing building,
describe last prior use . ) &aobga tglaw'S'nob
2 . Proposed Use of :roperty: tA114= c...vl'nWy
sh
Proposed Use (Chec - where applicable and provide floor area for
each use .
USE --BOSS FLOOR AREA
_General Office sq '+
_Professional Office sq.
_Retail Sales _ sq. ft .
_hotel , Hotel sq. =_ .
—Who lesale/Distri::u_ion sq. ft .
_Fast Food sq. ft .
_Restaurant, barroom -sq. ft .
—Manufacturer sq. ft .
XOther (specify) ohou5 y oo �n }Zoo sq. ft .
3 . Number of Employees in Maximum Shift : 10
II . SITE DEVELOPMENT DATA
Area of Parcel acres = 4%oo0 sq. f=.
i4aximum Size Building Allowed _sq . ft.
Disposition of ?arcel :
Existing
Building Area 560o sq. ft . of parcel
Paved Area "'_oSo sq . ft . 3 ; of parcel
( including walks )
Green Area O =q. ft . O $ of parcel
Proposed
Building Area 13a _ , . _ p__ ^__
Paved Area 4300 -; • f= • S'" of parcel
; including wall
Green Area p s;. ft . 0 of parcel
Building Set_ac s
Front Yard �54. Rear Yard 4o4
Left Side yard Right Side Yard
AcFess (check where applicable)
Town highway County _5ta`e
Length of =rontageilO 2_oo�4
Number of Park4n, Spaces : Existing 30 =roposed �o
Town Water: ✓ Yes No
Town Sewer: _Yes --,;; No
III . BBUILDING
Type o Z MEui 1di: ; _ _ '_e bui l t :
Height of Bul i d ng a': ^ye ik
Number of seat-- --ihere app: .cable' : Q
Li Et the owner ' s -_a:r:es and zoning on the ad-ioining properties :
:North : _ _ - _--- A
Name : ` � P ou�. Ptame : _F" wl ns /NnAs ny Gly-ang
Zone : MR5 Zore : bias f
East: West :
Name : 1.n0manc,. Avena:e. Name : 111®rtrn- N-enve_
Zone : M2.5 - - Zone : Mes
A COMPLETE APPLICM. -r%:1 :`� NECESSARY FOR PLACEMENT ON THE QUEENSBi =Y
PLANNING BOARD AGENDA - APPL1CAev'= PLEASE READ
op_; ea of your sit-
The l nning ' ffi_e requiro �/
:.---
application and maps one original application and 13 copies w_ _--
narrative and supporting Yeports , if
applicable . Also,
the deed a::d survey -,!a- . Review fees as apr'_icaole .
Section 179-35 : Application and Fees for Site Plan
Approval : in addition to the fee listed on the schedule of fee:
the Planning Board may charge a fee to developers of pro1je•= =s
requiring legal and technical review provided th_a t the fee charge '.
reflects the actual cost of legal and technical aSsiEtance to tie
Planning Board . This fee is not to exceed One Thousand
Dollars without Notice to the applicant.
Any modifica`_i .ns or stipulation on a site plan which
approved by the _ _a.nning Board shall be identified on a rev. --=-.
site plan and pre zed to the Planning Office ia_ -,.in :.o
the meeting at rif' _•=^ the site pla: is appr_vea .
Other permi`_ ...ay be required for Cons ti ion_ or alter-`
subsequent to a.__ :,.,al by the Planning Board •or =�ning Board
Appeals . applicants responsibiii _y to obtain these .
** * I , the un^a:s ` ~new have thoroughly read and understand
instructions for =;_bmission and the checklist, and agree to =.. .
submission requirements . Please read the attached and sign be'_c:; :
w
AUTHORIEA710N To AC!A AGENT FOR
I,
(seller, owner) of premises Located at
Tax Map Number hereby designate
as my agent regarding an application for (Subdivision, Site Plan Review, Variance) of the
above premises.
Deed Reference Book Page Date
Does the above parcel represent owner's entire contiguous holdings? Please attach
explanation.
� r
Signed: Date:
' rrrrrrprrrrrrrrrrrrrrrrrrrtrrrrrrrrrrrrrtrrrrrrrrrrrrrrrrrtrtrrrrrrrrrrrrrrrrrrrrrr
PLEASE READ AND SIGN
.The parties hereto consent that the proceedings which result from the within
application may be tape-recorded and transcribed by the Town Clerk or his agent and
that such minutes as may be transcribed shall constitute the official record of all
proceedings regarding this application, unless the same may vary from the handwritten
minutes taken by the Town Clerk or the Secretary of the Planning Board or Zoning Board
of Appeals, in which event the handwritten minutes as to such inconsistencies shall be
deemed the offi/ciiaal record."
Applicant's Signature
Date:
n OP-L
1416.1121117)—Teat 12 "—
PROJECT I.D.NUMBER 817.21 SEAR
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. APPLICANT/SPONSOR 2. PROJECT NAME
Ckxv1 d 5Aa ,nn,- 6'arn1e s DLV games u�a
S. PROJECT LOCATION:
Municipality u tx County T Q
t. PRECISE LOCATION( yrul
($treat`address /nnW d� road Interaectlons,prominent landmarks,*to.,or provide map)
('OYYIQ,Y'(3 kT'a\4YlG. `2hWC M'a I-V.Z2Y'm_' ecal t QUree1.15" C5e2 rr% �
S. IS PROPOSED A 10
❑NOW Expansion ❑Modification/alteration
8. DESCRIBE PROJFF,c T BRIEFLyy:
oddA�oY,to QCAS'1�Y1L� �u.ldlnq
7. AMOUNT OF LAND AFFETC�TED:
Initially B.00a 5 �f' aar ' Ultimately
8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS?
El Yea jWpL(No It No,describe briefly ()On-CcrI1(oy r„y-, vn'r_1n cr,VA MR"S ZSMP
9. VH t IS PRESENT LAND USE IN VICINITY OF PROJECT?
PQ Residential ❑Industrial 19commerclal ❑Agriculture ❑Park(Forest/Open space ❑Other
Describe:
10. DOES ACTION INVOLVE A PERMIT APPROVAL,OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY(F STATE OR LOCAL(? ,. EDERAL,
El Yes /`�yl No It yes,list agency(s)and permiUapprovals
11. DOES ANY, SpECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL?
❑Yes ,I`'(�(No It yea,list agency name and permlUapprovai
12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMITIAPPROVAL REQUIRE MODIFICATION?
❑Yes No
1 CERTIFY THAT THE INFORMATION
� PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
APplicant/spo sor name: ) yA/151.lZ.Wl1(1e, par nes Date:
Signature' L/ J
It 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
PART II—ENVIRONMENTAL ASSESSMENT (ro oe . •pleted by Agency)
A. DOES ACTION Ex EEO ANY TYPE I THRESHOLD IN 6 NYCRR,PART$17.121 If yes,coordinate the review process and use the FULL EAF.
❑Yee o
B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR,PART 617.6? If No,a negative declaration
may be supers by another Involved agency.
❑Yes o
C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING:(Answers may be handwritten,If legible)
Cl. Existing air quality, surface or groundwater Quality or quantity, noise levels, existing traffic patterns, solid waste production or disposal,
potential for erosion,drainage or flooding problems?Explain briefly;
C2. Aesthetic,agricultural,archaeological,hlstoric,.or other natural or cultural resources;or community or neighborhood Character? Explain briefly:
/2n�
Cq. Vegetation or fauna,fish,shellfish or wildlife species,significant habitats,or threatened or endangered species? Explain briefly:
11—O
Cs. A community's existing plansor goals as officially adopted,or a change In use or intensity of use of land or other natural resources?Explain briefly.
/v
C5. Growth,subsequent development,or related activities likely to be Induced by the proposed action?Explain briefly.
_V_0
C6. Long term,short term,cumulative,or other affects not Identified In C1.C5?Explain briefly.
C7. Other Impacts(including changes In use of either quantity or type of energy)?Explain briefly.
J�
0. IS THERE,OR S NERE LIKELY TO BE,CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS?
❑Yea No If Yes,explain briefly
PART III—DETERMINATION OF SIGNIFICANCE (ro be completed by Agency)
INSTRUCTIONS: For each adverse effect Identified above,determine whether It Is substantial,large,Important or otherwise significant.
Each effect should be assessed In connection mith Its (a) setting (Le. urban or rural); (b) probability of occurring; (c) duration; (d)
Irreversibility;(a)geographic scope; and in magnitude. If necessary,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.
❑ Check this box If you have Identified one or more potentially large or significant adverse Impacts which MAY
ccur.Then proceed directly to the FULL EAF and/or prepare a positive declaration.
19 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:
IQwrJ QU4S'ag Rog
�, Dce,�Niw6 /3d.9�
NameTi AaencY
Print or Type Name of Respons,ble Office,In Lead Agency it e o aQpomr a Officer
Signature of Responjible Officer in Lead Agency I / Signature of iepare,(it different from responsible officer)ate
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