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Site Plan Application Revised Oct.2008 General Information Tax Parcel ID Number: Zoning District: Detailed Descriptio of Project [include current&proposed use]: Location of project: j QU2ei�E7K.✓' �QSpniG �S�YiCL�t �O�(C� Drive- Cioc ert-5 VI- /Vy 1 z ro Will the proposal require a Septic Variance from the Town Board of Health? /?a If the parcel has previous approvals, list application number(s): Applicant Name: ewrn C oi✓ Cf.+'� 9 Address: /oo ct v t 'b c/a V�� a e vd. 0o e-36 Malia N xo Home Phone L)aw n Wh to e-- Cell: Work Phone Fax,: 5f�r - YRrf- 4z36 67r - FI?q - gd16 E-Mail: NP •.ee/GAT 9n ewI.I e-az . at Agent's Name: Address: Home Phone Cell Work Phone:, Fax E-mail Owner's Name ,0e-enS &Lry aw*,i<- Address r 'ca! Sock yrNV 12ft6 Home Phone 141 Or-y a,n f Cell Work Phone fax D1�,/ E-mail. "t Town of Queensbury Planning Office- 742 Bay Road • Queensbury, NY 12804• 518-761-8220 2 Revised Oct.2008 Please provide maps/plans depicting the following items [if information is not submitted, an explanation of why must be provided] A. GENERAL SHOWN ON SHEET# 1 Title,Name,Address of applicant&person responsible for preparation of drawing -F a.c C-' 2 Deed I gqA4+a(-k $ 3 North arrow,Tax Map ID,date prepared and scale[minimum 1In.=40 ft.] M—�at—k 4 Boundaries of the property plotted to scale,zoning boundary "L[ . 5 Principal structures,accessory structures with exterior dimensions D 6 Site improvements incl.outdoor storage areas,driveways,parking areas,etc.: existing proposed u 7 Setbacks for all structures and improvements: existing&proposed 8 Elevations and floor plans of all proposed and affected structures A f B. WATER&SEWER SHOWN ON SHEET# 1 Project sewage disposal facilities,design details,construction details,flow rates,and number of bedrooms proposed A+I 2 Water supply [i.e. well] &septic on adjoining lots with separation distances to existing or proposed on-site water ��+ _a'i 5 supply and septic b` Uri 3 Separation distances for proposed sewage disposal system to well and water bodies N ;^ (� �-�-- 4 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 5 Percolation test location and results A r G G. PARKING/PERMEABLE AREAS SHOWN ON SHEET# 1 Number of spaces required for project including calculations and justification: existing&proposed Q. 2 No. of existing parking spaces, number to be removed, number to maintain and type of surfacing material [e.g., Q f ravel,paved] (� a.5 3 Provision for pedestrian and handicap access and parking: existing&proposedkta. D 4 Design details of ingress,egress,loading areas and cutting: existing&proposed b[d'I Aftacb 5 Location and character of green areas [existing and proposed], modification to green area, buffer zone to remain undisturbed !' _II �T�CVI 6 Lighting,location and design of all existing and proposed outdoor lighting D. ADDITIONAL SITE DEVELOPMENT AND MISCELLANEOUS SHOWN ON SHEET# 1 On-site&adjacent watercourses,streams,rivers,lake and wetlands M +ac k 2 Utility/energy distribution system[gas,electric,solar,telephone]: existing&proposed X5 b u,r 3 Location,design and construction details of all existing and proposed site improvements including: drains,culverts, retaining walls,fences,fire&emergency zones and hydrants,etc. N14 4 Square footage of bldg.area proposed for office,manufacturing,retail sales or other commercial activities: existing &proposed 0_4 b 9 (f e Signage: Location,size,type,design and setback: existing&proposed " I - �I-11— f Waiver Request: provide letter with application requesting any waivers: please reference specific items A-I-+ac l� g Commercial/Industrial Development requires submission of Landscaping, Stormwater Management, Grading & Lighting Plans )Wac k h Identification of Federal, State or County permits required for the project together with a record of application for all u necessa permits Town of Queensbury Planning Office- 742 Bay Road • Queensbury, NY 12804• 518-761-8220 5 Revised Oct.2008 REASON FOR REVIEW: APA/CEA/DEC/ACOE/NYS DOH PRE-SUBMISSION MEETING NOTES,• OUTSTANDING ITEMS TO BE ADDRESSED INCLUDE: =�P-4/y Y Nl-4 p Ae,4/1J 7-0 l)l-1 UJ Staff Member: Applicant/Agent: 7 GL` (�L� Date: )Ale q Town of Queensbury Planning Office- 742 Bay Road • Queensbury, NY 12804• 518-761-8220 6 Revised Oct.2008 14-16-4(11/9M—Text 12 1 PROJECT I.D.NUMBER 617.20 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/SP NSOR 2. P JECT NAME wwr t � 5ckoa! - "c rulow 3. PROJECT LOCATION: tiIJ / Municipality e e :S u.Y A/hee/er Count hlarecii 4. PRECISE LOCATION(Street address and ro d intersections,prominent landmarks,etc.,or provide map) 15' &Lrke- Drive., atceevt6bury A/y 12-?roq 5. IS PROPOSED ACTION: ❑New ❑Expansion cieModificationlaiteration 6. DESCRIBE PROJECT BRIEFLY: P� eb 3^may-eCt.✓ oW'-f'GI 5 `*✓cl ( t�leeeexSc.�wvv GIRsSroomS chi/drtln , /�Ondu - �ridctL R:oo - l. 0L y 7. AMOUNT OF LA D AFF`ECTED: i Initially J acres Ultimates • acres 8. WIOPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? Yes ❑No If No,describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? ❑Residential ❑Industrial 0 Commercial ❑Agriculture ❑Park/Forest/Open space Other oeJscrieb�: d?orde d CYQ%e Ywf� � 6f"CGrlrc��r rThn �vrke �m +3 � 10. DOES ACTION(INVOLVE A PERMIT APPROVAL,OR FUNDING,NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY(FEDERAL, STATE OR LOCAL)? ❑Yes No if yes,list agency(s)and permit/approvals 11. DOES ANY ASPEyT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ❑Yes �Jn�'/No It yes,list agency name and permitlapproval 12. AS A RESULT OF P OPOSED ACTION WILL EXISTING PERMIT/APPROVAL REQUIRE MODIFICATION? ❑Yes No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant/ponsor ame:bawn1nJ�teeleis Date: .1 0� Signature: 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 1 Town of Queensbury Planning Office- 742 Bay Road • Queensbury, NY 12804• 518-761-8220 7 PART 11 - IMPACT ASSESSMENT To be completed by Lead Agency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR,PART 617.4? If yes,coordinate the review process and use the FULL EAF. Yes ❑ No B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR,PART 617.6? If No,a negative declaration may be superseded by another involved agency. Yes No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING:(Answers may be handwritten,if legible) C1. Existing air quality,surface or groundwater quality or quantity,noise levels,existing traffic pattern,solid waste production or disposal, potential for erosion,drainage or flooding problems? Explain briefly: C2. Aesthetic,agricultural,archaeological,historic,or other natural or cultural resources;or community or neighborhood character?Explain briefly: C3. Vegetation or fauna,fish,shellfish or wildlife species,significant habitats,or threatened or endangered species?Explain briefly: C4. A community's existing plans or goals as officially adopted,or a change in use or intensity of use of land or other natural resources?Explain briefly: C5. Growth,subsequent development,or related activities likely to be induced by the proposed action?Explain briefly: C6. Long term,short term,cumulative,or other effects not identified in C1-05? Explain briefly: C7. Other impacts(including changes in use of either quantity or type of energy)? Explain briefly: D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRONMENTAL AREA(CEA)? ElYes No If Yes,explain briefly: E. IS THERE,OR IS 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 effect identified above,determine whether it is substantial,large,important or otherwise significant. Each effect should be assessed in connection with its(a)setting(i.e. urban or rural); (b)probability of occurring;(c)duration;(d)irreversibility; (e) geographic scope; and (f)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. If question D of Part II was checked yes,the determination of significance must evaluate the potential impact of the proposed action on the environmental characteristics of the CEA. El Check this box ifyou 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 ifyou 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 Lead Agency Date Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Signature of Responsible Officer in Lead Agency Signature of Preparer(If different from responsible officer) Reset Maps Page 1 of 2 Trip: 27.8 mi, 26 min Mkrosoft" Virtual E4�t,TM �. s h�rrrtor Dh hrhr,or Q d� rro/ .gc Q '- --- �, [254�A�nation R(I - - t f o07 ? n i '! Aviaticx�Awl�a 3 St 4. r & Aviation Mall Rsf m m I a � G-I o Ct Jnsick nib 4` gyp. o ©3008 Navteq.© 008 Morosoft This map is based on the map view in the browser window when you clicked Print. A: 100 Saratoga Village Blvd, Ballston Spa, N... B: 15 Burke Dr, Queensbury, NY 12804-1977 http://maps.live.com/print.aspx?mkt=en-us&z=15&s=r&cp=r6mvtw8vsg66&pt=pf&rs=v8... 1/14/2009 Revised Oct. 2008 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: <M0.50Y661 S` �'��� SOCcG+y -A( isrrin Designates: Ne;UJ►r1Q[�C�Utnl0.�GiGI �DOj D0.Wri As agent regarding: Variance Site Plan Subdivision For Tax Map No.: Section Block Lot Deed Ref e: Book Page Date OWNER SIGNATURE: / DATE: APPLICANT'S AGENT F R Complete the following if the APPLICANT is unable to attend the meeting or wishes to be represented by another party: Owner: Designates: As agent regarding: Variance Site Plan Subdivision For Tax Map No.: Section Block Lot Deed Reference: Book Page Date OWNER SIGNATURE: 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. 5.) 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: I, 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 abov . SIGNATURE OF APPLICANT: ,- — DATE: 1-4-02 SIGNATURE OF AGENT: DATE: Town of Queensbury Planning Office- 742 Bay Road • Queensbury, NY 12804• 518-761-8220 9