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Site Plan Application2 Site Plan Review application – Revised October 2016 Town of Queensbury Planning Office-742 Bay Road, Queensbury, NY 12804 General Information Tax Parcel ID Number: ____________________ Zoning District: ____________________ Lot size: _____________________ Detailed Description of Project [includes current & proposed use]: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Location of project: ________________________________________________________________________________ Applicant Name: Address: Home Phone Cell: Work Phone Fax E-Mail: Agent’s Name: Address: Home Phone Cell: Work Phone Fax E-mail Owner’s Name Address Home Phone Cell Work Phone Fax E-mail 3 Site Plan Review application – Revised October 2016 Town of Queensbury Planning Office-742 Bay Road, Queensbury, NY 12804 Site Development Data Area / Type Existing sq. ft. Proposed Addition sq. ft. Total sq. ft. A. Building footprint B. Detached Garage C. Accessory Structure(s) D. Paved, gravel or other hard surfaced area E. Porches / Decks F. Other G. Total Non-Permeable [Add A-F] H. Parcel Area [43,560 sq. ft. / acre] I. Percentage of Impermeable Area of Site [I=G/H] Setback Requirements Area Required Existing Proposed Front [1] Front [2] Shoreline Side Yard [1] Side Yard [2] Rear Yard [1] Rear Yard [2] Travel Corridor Height [max] Permeability No. of parking spaces 4 Site Plan Review application – Revised October 2016 Town of Queensbury Planning Office-742 Bay Road, Queensbury, NY 12804 Additional Project Information 1. Will the proposal require a Septic Variance from the Town Board of Health? _______________ 2. If the parcel has previous approvals, list application number(s): _________________________ 3. Does this project require coverage under the New York State Pollutant Discharge Elimination System (SPDES) Permit Program ? _______________ 4. Estimated project duration: Start Date __________ End Date __________ 5. Estimated total cost of project: _______________ 6. Total area of land disturbance for project: _______________ Floor Area Ratio Worksheet FLOOR AREA RATIO (FAR) -- The relationship of building size to lot size, derived by dividing the total building floor area by the lot size in square feet, yielding a percentage. Zoning District Symbol Floor Area Ratio [FAR] Waterfront Residential WR 0.22 Commercial Moderate/ Intensive CM/ CI 0.3 A. The combined area of all square footage, as measure from exterior walls of all structures on the property, including all floors of the structures, garages, basements and attics with more than five (5) feet of ceiling height and covered porches. Building square footage does not include: Open deck, docks and that portion of covered docks extending over water and one storage shed of one hundred twenty (120) square feet or less. Any additional sheds will be included. (See “FLOOR AREA RATIO”). B. Commercial or industrial: the total area in square feet as measured from the exterior of the outside walls of a building or structure, and when applicable, the sum total of all floor areas of the principal and accessory buildings or structures on the project site. A. Parcel Area ___________________________ sq. ft. B. Existing Floor Area ___________________________ sq. ft. [see above definition] C. Proposed Additional Floor Area ___________________________ sq. ft. D. Proposed Total Floor Area ___________________________ sq. ft. E. Total Allowable Floor Area ___________________________ (Area x _____) [see above table] *If D is larger than E. a variance or revisions to your plan may be needed. Consult with Staff. 5 Site Plan Review application – Revised October 2016 Town of Queensbury Planning Office-742 Bay Road, Queensbury, NY 12804 § 179-9-080 Requirements for Site Plan Approval. The Planning Board shall not approve a Site Plan unless it first determines that such site plan meets the following Standards. Please prepare responses to each of the following topics: STANDARDS A. The proposed project furthers or is consistent with the policies of the Town’s Comprehensive Plan. B. The proposed project complies with all other requirements of this Chapter, including the site plan review standards as set forth in Paragraph F of this section, the dimensional, bulk and density regulations of the zoning district in which it is proposed to be located (Article 3 and Table 1), the applicable requirements of all other Articles that apply. C. The site plan encourages pedestrian activity internally and, if practicable, to and from the site with pedestrian paths or sidewalks connected to adjacent areas. D. The site plan must conform to Chapter 136 Sewage and Sewage Disposal, Chapter 147 Stormwater Management Local Law, and other applicable local laws. E. The proposed use shall be in harmony with the general purpose or intent of this Chapter, specifically taking into account the location, character and size of the proposed use and the description and purpose of the district in which such use is proposed, the nature and intensity of the activities to be involved in or conducted in connection with the proposed use and the nature and rate of any increase in the burden on supporting public services and facilities which will follow the approval of the proposed use. F. The establishment, maintenance and operation of the proposed use will not create public hazards from traffic, traffic congestion or the parking of vehicles and/or equipment or be otherwise detrimental to the health, safety or general welfare of persons residing or working in the neighborhood or to the general welfare of the town. Traffic access and circulation, road intersections, road and driveway widths and traffic controls will be adequate. G. Off-street parking and l9oading facilities will be appropriately located and arranged and sufficient to meet traffic anticipated to be generated by the new use. The establishment of vehicle links between parking areas of adjacent properties are provided where feasible. This furthers the Town’s goal of reducing curb cuts and reducing congestion. A twenty-foot wide connection is required. If adjacent properties are either undeveloped or previously developed without having made provision for future linkage, then a future connection must be identified and provided for in the site plan under review for such future linkage when the time arises. The Planning Board may require proof that the applicant has made contact with adjacent property owners for purposes of coordinating linkages with adjacent properties. H. The project shall not have an undue adverse impact upon the natural, scenic, aesthetic, ecological, wildlife, historic, recreational or open space resources of the town or the Adirondack Park or upon the adequate provision of supporting facilities and services made necessary by the project, taking into account the commercial, industrial, residential, recreational or other benefits that might be derived from the project. In making the determination hereunder, the Planning Board shall consider those factors pertinent to the project contained in the development considerations set forth herein under § 179-9-080 of this Chapter, and in so doing, the Planning Board shall make a net overall evaluation of the project in relation to the development objectives and general guidelines set forth in § 179-9-080 of this Article. I. The provision for and arrangement of pedestrian traffic access and circulation, walkway structures, control of intersections with vehicular traffic and overall pedestrian convenience shall be safe and adequate for pedestrian movement. Pedestrian connections between adjacent sites shall be provided to encourage pedestrian use. J. Stormwater drainage facilities will prevent an increase of post development drainage flows as compared to pre-development drainage flows. Drainage of the site shall recharge ground water to the extent practical. Surface waters flowing off-site shall not degrade any streams or adversely affect drainage on adjacent properties or public roads. Facilities shall be in conformance with the drainage standards of Chapter 147 of the Town Code and the Town of Queensbury Subdivision Regulations where applicable. K. The water supply and sewage disposal facilities will be adequate and will meet all applicable and current requirements set forth by Department of Health regulations and Chapter 136 of the Town Code. L. The adequacy, type and arrangement of trees, shrubs and other suitable plantings, landscaping and screening shall effectively provide a visual and/or noise buffer between the applicants and adjoining lands, including the maximum retention of existing vegetation and maintenance, including replacement of dead or deceased plants. M. Fire lanes, emergency zones and fire hydrants will be adequate and meet the needs and requirements of emergency service providers. N. The design of structures, roadways and landscaping in areas susceptible to ponding, flooding and/or erosion will minimize or avoid such impacts to the maximum extent practicable. O. The site plan conforms to the design standards, landscaping standards and performance standards of this chapter. James Stokes 45 Alessia Dr Queensbury, NY 12804 Response to A-O Standards – Stokes Property 45 Alessia Dr The following are responses to questions A thru O of the site plan review standards. A. The project consists of improving recreational access, 60 feet long and 8 feet wide, to a stream at the northeastern portion of the lot. It creat es a foot traffic pathway that would provide safer, easier, and less steep access to the edge of the stream. In addition, it stabilizes the stream bank with riprap, grass, native plants and covered with wood chips. B. This project requires approval from the US Army Corp of Engineers and NY DEC. Those permits have been obtained. C. The site is on the property of a single-family residence and therefore pedestrian activities are limited. D. The project does not alter any of the existing Sewage and Sewage Disposal facilities of th is single-family residence. E. The project improves foot traffic access to the stream. It is located behind the current residence and access is limited to residents and guests. There is no additional burden on public services and facilities. F. The existing driveway and entrance to the residence are not impacted by this project. G. The single-family residence has adequate off-street parking for family and guests. Improving the pathway will not increase the amount of traffic or guests requiring parking. H. To ensure that this project would not have an undue adverse impact, the services of Delaware Engineering and their Senior Scientists were engaged. The project engaged with the US Army Corp of Engineers and the NYDEC to meet Federal and State requirements. I. The property is accessed only from Alessia Dr. along a private driveway. J. The project does not affect any of the stormwater drainage facilities associated with the residence. K. Current water supply and sewage disposal facilities and not impacted by this project. L. Native grass and plants have been identified to be planted to maintain consistence with the surrounding environment. Along with the plantings, emergent vegetation will colonize the edges of the stream. M. The site is located off a town road, Alessia Dr and is adequate for emergency vehicle access. A fire hydrant id located just of the southeast corner of the residential site. N. Specific targeted actions are being taken to minimize erosion. O. The site plan takes as many steps as possible to conform to all design standards and reduce environmental impacts for the project. 6 Site Plan Review application – Revised October 2016 Town of Queensbury Planning Office-742 Bay Road, Queensbury, NY 12804 § 179-9-050 Checklist-Application for Site Plan Review. Application materials and site plan shall include sufficient information for the Board to review and provide a decision. The applicant is to provide a site plan drawing and all attachments that address items A-V. The applicant may request a waiver from A-V and is to provide reasons for waiver(s) requested. Please label information to be submitted. REQUIREMENTS Sheet # A. A vicinity map drawn at the scale that shows the relationship of the proposal to existing community facilities which affect or serve it, such as roads, shopping areas, schools, etc. The map shall also show all properties, identify owners, subdivisions, streets and easements within 500 feet of the property. Such a sketch may be superimposed on a United States Geological Survey map of the area. B. The site plan shall be drawn at a scale of forty feet to the inch (1” = 40 feet) or such other scale as the Planning Board may deem appropriate, on standard 24” x 36” sheets, with continuation on 8 l/2 “x 11” sheets as necessary for written information. The information listed below shall be shown on the site plan and continuation sheets. C. Name of the project, boundaries, date, north arrow, and scale of the plan. D. Name and address of the owner of record, developer, and seal of the engineer, architect or landscape architect. If the applicant is not the record owner, a letter of authorization shall be required from the owner. E. The location and use of all existing and proposed structures within the property, including all dimensions of height and floor area, all exterior entrances, and all anticipated future additions and alterations. F. The location of all present and proposed public and private ways, off-street parking areas, driveways, outdoor storage areas, sidewalks, ramps, curbs, paths, landscaping, walls and fences. Location, type and screening details for all waste disposal containers shall also be shown. G. The location, height, intensity and bulb type (sodium, incandescent, etc.) of all external lighting fixtures. The direction of illumination and methods to eliminate glare onto adjoining properties must also be shown in compliance with § 179-6-020. H. The location, height, size, materials and design of all proposed signs. I. The location of all present and proposed utility systems including: 1. Sewage or septic system; 2. Water supply system; 3. Telephone, cable and electrical systems; and 4. Storm drainage system including existing and proposed drain lines, culverts, catch basins, headwalls, endwalls, hydrants, manholes and drainage swales. J. Plans to prevent the pollution of surface or groundwater, erosion of soil both during and after construction, excessive runoff and flooding of other properties, as applicable. A Stormwater Pollution Prevention Plan (SWPPP) for all land development activities (excluding agricultural activities) on the site that results in land disturbance of one acre or more. A SWPPP shall comply with the requirements of the DEC SPDES MS-4 General Permit and Chapter 147 of the Town of Queensbury Code. It shall be at the discretion of the Planning Board as to whether a SWPPP or an erosion and control plan shall be required for a site plan review project land disturbance of less than one acre. K. Existing and proposed topography at two-foot contour intervals, or such other contour interval as the Planning Board shall allow. All elevations shall refer to the nearest United States Coastal and Geodetic Bench Mark. If any portion of the parcel is within the 100-year floodplain, the area will be shown and base flood elevations given. Areas shall be indicated within the proposed site and within 50 feet of the proposed site where soil removal or filling is required, showing the approximate volume in cubic yards. L. A landscape plan showing all existing natural land features than may influence the design of the proposed use such as rock outcrops, stands of trees, single trees eight or more inches in diameter, forest cover and water sources and all proposed changes to these features, including sizes and types of plants. Water sources include ponds, lakes, wetlands and watercourses, aquifers, floodplains and drainage retention areas. M. Land Use District boundaries within 500 feet of the site’s perimeter shall be drawn and identified on the site plan, as well as any Overlay Districts that apply to the property. 7 Site Plan Review application – Revised October 2016 Town of Queensbury Planning Office-742 Bay Road, Queensbury, NY 12804 REQUIREMENTS (CONTINUED) Sheet # N. Traffic flow patterns within the site, entrances and exits, loading and unloading areas, as well as curb cuts on the site and within 100 feet of the site. The Planning Board may, at its discretion, require a detailed traffic study for large developments or for those in heavy traffic areas, which shall include: 1. The projected number of motor vehicle trips to enter or leave the site, estimated for weekly and annual peak hour traffic levels; 2. The projected traffic flow pattern including vehicular movements at all major intersections likely to be affected by the proposed use of the site; 3. The impact of this traffic on levels of service on abutting public streets and at affected intersections. Existing and proposed weekly and annual peak hour traffic levels and road capacity levels shall also be given. O. For new construction or alterations to any structure, a table containing the following information shall be included: 1. Estimated area of structure to be used for particular purposes such as retain operation, office, Storage, etc.; 2. Estimated maximum number of employees; 3. Maximum seating capacity, where applicable; and 4. Number of parking spaces existing and required for the intended use. P. 1. Floor Plans. 2. Elevations at a scale of one-quarter inch equals one foot (1/4” = 1 foot) for all exterior facades of the proposed structure(s) and/or alterations to or expansions of existing facades, showing design features and indicating the type and color of materials to be used. Q. Soil logs, water supply well and percolation test results, and storm water runoff calculations as needed to determine and mitigate project impacts. R. Plans for disposal of construction and demolition waste, either on-site or at an approved disposal facility. S. Plans for snow removal, including location(s) of on-site snow storage. T. An Environmental Assessment Form (“EAF”) as required by the SEQRA regulations, with Part 1 completed by the Applicant shall be submitted as part of the application. If the proposed project requires a special use permit and an EAF has been submitted in conjunction with a special use permit application, a duplicate EAF is not required for the site plan application. U. If an application is for a parcel or parcels on which more than one use is proposed, the applicant may submit a single application for all such uses, provided the proposed uses are accurately delineated on a site plan drawn pursuant to the requirements set forth above. The Planning Board may grant the application with respect to some proposed uses and not others. For purposes of reviewing an application (and for SEQRA compliance) all proposed uses on a single parcel or on contiguous parcels shall be considered together. V. A brief narrative statement on how the project proposed for review furthers or is consistent with the vision, goals and policies in the Town’s Comprehensive Plan. Town of Queensbury Site Plan Pre-Submission Conference Form / Section 179-9-040 1.Applicant Name: __________________________________________________ 2.Tax Map ID ________________ Location: _______________________ 3.Zoning Classification __________ 4. Reason for Review: __________________________________________________________ 5.Zoning Section #: ________________________ 6. Pre-Submission Meeting Notes:Provided Outstanding; Please provide by Deed ____ _____________ General Information complete ____ _____________ Site Development Data Complete ____ _____________ Setback Requirements Complete ____ _____________ Additional Project Information Complete ____ _____________ FAR addressed ____ _____________ Requirements for Site Plan-Standards ____ _____________ Checklist items addressed ____ _____________ Environmental Form completed ____ _____________ Signature Page completed ____ _____________ Staff Representative: ________________________________ Applicant / Agent: ________________________________ Date: ___________ James Stokes 315.-1-1.2 45 Alessia Drive MDR 5.01 AC (SUB2-2009-RR3A) Project started to improve recreational access of 60 ft in length and 8 ft wide to stream/wetland area. 179-3-040 MDR, Chapter 94 Wetland 179-6-050shoreline X X X X X NA NA X X X Laura Moore via email 02/01/2022 Applicant proposes to complete a 60 ft length recreational path that is to be 8 ft wide from the house to the wetland area located at the Northeast corner of the property. The project is subject to site plan for Shoreline disturbance and a Freshwater Wetlands for doing work within 100 ft. The project was subject to a Notice of Violation and the applicant has been working with the Corp of Engineers to complete the permit requirements and to submit the project for review. Items reviewed - site plan application, freshwater wetlands permit, arm corp permit information, photos Items to be updated or provided 1) page 5 Responses needed for A-O 2) page 6 and 7 Checklist to be completed - identifying materials to be submitted. This is a tabled of contents if there are items not being provided then it should be identified as a waiver. 3) site drawing - the wetlands that have been delineated/flagged should be placed on an updated survey; the drawing should include the path. 4) there are some items in the packet that may not be necessary ie two seqr forms - one in the Town's application and one in the Army Corp - you only need the one in the army corp. 8 9 Site Plan Review application – Revised October 2016 Town of Queensbury Planning Office-742 Bay Road, Queensbury, NY 12804 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.: _____ Section _____ 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: ____________________________________ 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 above. ____________________________ ___________________________ __________________ Signature [Applicant] Print Name [Applicant] Date signed ____________________________ ___________________________ __________________ Signature [Agent] Print Name [Agent] Date signed Short Environmental Assessment Form Part 1 - Project Information Instructions for Completing Part 1 - Project Information. The applicant or project sponsor is responsible for the completion of Part 1. 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. Complete all items in Part 1. You may also provide any additional information which you believe will be needed by or useful to the lead agency; attach additional pages as necessary to supplement any item. Part 1 - Project and Sponsor Information Name of Action or Project: Project Location (describe, and attach a location map): Brief Description of Proposed Action: Name of Applicant or Sponsor: Telephone: E-Mail: Address: City/PO: State: Zip Code: 1. Does the proposed action only involve the legislative adoption of a plan, local law, ordinance, administrative rule, or regulation? If Yes, attach a narrative description of the intent of the proposed action and the environmental resources that may be affected in the municipality and proceed to Part 2. If no, continue to question 2. NO YES 2. Does the proposed action require a permit, approval or funding from any other governmental Agency? If Yes, list agency(s) name and permit or approval: NO YES 3.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 4. Check all land uses that occur on, adjoining and near the proposed action. 9 Urban 9 Rural (non-agriculture) 9 Industrial 9 Commercial 9 Residential (suburban) 9 Forest 9 Agriculture 9 Aquatic 9 Other (specify): _________________________ 9 Parkland Page 1 of 3 Page 2 of 3 5. Is the proposed action, a. A permitted use under the zoning regulations? b. Consistent with the adopted comprehensive plan? NO YES N/A 6. Is the proposed action consistent with the predominant character of the existing built or natural landscape? NO YES 7. Is the site of the proposed action located in, or does it adjoin, a state listed Critical Environmental Area? If Yes, identify: __________________________________________________________________________ _______________________________________________________________________________________ NO YES 8. a. Will the proposed action result in a substantial increase in traffic above present levels? b. Are public transportation service(s) available at or near the site of the proposed action? c. Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action? NO YES 9. Does the proposed action meet or exceed the state energy code requirements? If the proposed action will exceed requirements, describe design features and technologies: _______________________________________________________________________________________ _______________________________________________________________________________________ NO YES 10. Will the proposed action connect to an existing public/private water supply? If No, describe method for providing potable water: ______________________________________ _______________________________________________________________________________________ NO YES 11. Will the proposed action connect to existing wastewater utilities? If No, describe method for providing wastewater treatment: ________________________________ _______________________________________________________________________________________ NO YES 12. a. Does the site contain a structure that is listed on either the State or National Register of Historic Places? b. Is the proposed action located in an archeological sensitive area? NO YES 13. a. Does any portion of the site of the proposed action, or lands adjoining the proposed action, contain wetlands or other waterbodies regulated by a federal, state or local agency? b. Would the proposed action physically alter, or encroach into, any existing wetland or waterbody? If Yes, identify the wetland or waterbody and extent of alterations in square feet or acres: _______________ _______________________________________________________________________________________ _______________________________________________________________________________________ NO YES 14. Identify the typical habitat types that occur on, or are likely to be found on the project site. Check all that apply: † Shoreline † Forest † Agricultural/grasslands † Early mid-successional † Wetland † Urban † Suburban 15. Does the site of the proposed action contain any species of animal, or associated habitats, listed by the State or Federal government as threatened or endangered? NO YES 16. Is the project site located in the 100 year flood plain?NO YES 17. Will the proposed action create storm water discharge, either from point or non-point sources? If Yes, a. Will storm water discharges flow to adjacent properties? † NO † YES b. Will storm water discharges be directed to established conveyance systems (runoff and storm drains)? If Yes, briefly describe: † NO † YES _______________________________________________________________________________________ _______________________________________________________________________________________ NO YES 18. Does the proposed action include construction or other activities that result in the impoundment of water or other liquids (e.g. retention pond, waste lagoon, dam)? If Yes, explain purpose and size: ____________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ NO YES 19. Has the site of the proposed action or an adjoining property been the location of an active or closed solid waste management facility? If Yes, describe: _________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ NO YES 20. Has the site of the proposed action or an adjoining property been the subject of remediation (ongoing or completed) for hazardous waste? If Yes, describe: __________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ NO YES I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE Applicant/sponsor name: ___________________________________________ Date: ___________________________ Signature: _______________________________________________________ Page 3 of 3 Page 1 of 2 Agency Use Only [If applicable] Project: Date: Short Environmental Assessment Form Part 2 - Impact Assessment Part 2 is to be completed by the Lead Agency. Answer all of the following questions in Part 2 using the information contained in Part 1 and other materials submitted by the project sponsor or otherwise available to the reviewer. When answering the questions the reviewer should be guided by the concept “Have my responses been reasonable considering the scale and context of the proposed action?” No, or small impact may occur Moderate to large impact may occur 1. Will the proposed action create a material conflict with an adopted land use plan or zoning regulations? 2.Will the proposed action result in a change in the use or intensity of use of land? 3.Will the proposed action impair the character or quality of the existing community? 4.Will the proposed action have an impact on the environmental characteristics that caused the establishment of a Critical Environmental Area (CEA)? 5.Will the proposed action result in an adverse change in the existing level of traffic or affect existing infrastructure for mass transit, biking or walkway? 6.Will the proposed action cause an increase in the use of energy and it fails to incorporate reasonably available energy conservation or renewable energy opportunities? 7.Will the proposed action impact existing: a. public / private water supplies? b. public / private wastewater treatment utilities? 8.Will the proposed action impair the character or quality of important historic, archaeological, architectural or aesthetic resources? 9.Will the proposed action result in an adverse change to natural resources (e.g., wetlands, waterbodies, groundwater, air quality, flora and fauna)? 10.Will the proposed action result in an increase in the potential for erosion, flooding or drainage problems? 11.Will the proposed action create a hazard to environmental resources or human health? Page 2 of 2 For every question in Part 2 that was answered “moderate to large impact may occur”, or if there is a need to explain why a particular element of the proposed action may or will not result in a significant adverse environmental impact, please complete Part 3. Part 3 should, in sufficient detail, identify the impact, including any measures or design elements that have been included by the project sponsor to avoid or reduce impacts. Part 3 should also explain how the lead agency determined that the impact may or will not be significant. Each potential impact should be assessed considering its setting, probability of occurring, duration, irreversibility, geographic scope and magnitude. Also consider the potential for short- term, long-term and cumulative impacts. Check this box if you have determined, based on the information and analysis above, and any supporting documentation, that the proposed action may result in one or more potentially large or significant adverse impacts and an environmental impact statement is required. 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. _________________________________________________ _______________________________________________ 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) Short Environmental Assessment Form Part 3 Determination of Significance Agency Use Only [If applicable] Project: Date: