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4.27
w 4.27 LOCAL LAWS\SET PUBLIC HEARINGS\Chapter 179—Westem Ave—HHHN—Office to NR—5-16-2022 RESOLUTION SETTING PUBLIC HEARING ON PROPOSED LOCAL LAW NO. OF 2022 TO AMEND CHAPTER 179 "ZONING" OF QUEENSBURY TOWN CODE TO AMEND ZONING MAP FOR A PORTION OF TAX MAP PARCEL NO. 309.7-1-55 RESOLUTION NO. ,2022 INTRODUCED BY: WHO MOVED FOR ITS ADOPTION SECONDED BY: WHEREAS, Hudson Headwaters Health Network (HHHN) submitted a zoning change application to the Queensbury Town Clerk's Office on or about May 12th, 2022 to allow for a change of zoning district designation for a portion of Tax Map Parcel No.: 309.7-1-55 from Office (0)to Neighborhood Residential (NR), and WHEREAS, the Queensbury Town Board wishes to change the zoning district designation for a portion of Tax Map Parcel No.: 309.7-1-55 from. Office (0) to Neighborhood Residential (NR) as presented at this Town Board meeting, including a proposed revision to the Town's Zoning Map associated with the Zoning Code (collectively, the "proposed zoning revisions"), and WHEREAS, in accordance with General Municipal Law §239-m, before enacting the proposed zoning revisions the Town must first refer them to the Warren County Planning Board for its recommendations, and WHEREAS, the proposed zoning revisions must undergo an environmental review pursuant to the State Environmental Quality Review Act (SEQRA) prior to adoption and enactment,and WHEREAS, the Town Board wishes to be Lead Agency for the required SEQRA environmental review and H HN has prepared Part I of a Full Environmental Assessment Form(EAF) for use in the environmental review, and WHEREAS, Municipal Home Rule Law §20 requires the Town Board to hold a public hearing prior to the adoption of any Local Law; NOW,THEREFORE, BE IT RESOLVED, that the Queensbury Town Board hereby authorizes and directs the Town Clerk to forward a copy of the proposed zoning revisions, together with a copy of the completed Part I of the Full EAF, to the Warren County Planning Board for its review and recommendations, and BE IT FURTHER, RESOLVED, that the Town Board hereby declares its intention to be Lead Agency for SEQRA review of the proposed zoning revisions and directs the Town Clerk to send a copy of the proposed zoning revisions, together with a copy of the completed Part I of the Full EAF, and a certified copy of this Resolution stating the Town Board's intention to be Lead Agency for SEQRA review, to any other Involved Agencies as required by law, and BE IT FURTHER, RESOLVED, that the Town Board shall meet and hold a Public Hearing at the Queensbury Activities Center, 742 Bay Road, Queensbury at 7:00 p.m. on Monday, June 13`h 2022 to hear all interested persons concerning the proposed revisions to the Town's Zoning Code and enactment of Local Law No.: of 2022 To Amend Chapter 179 "Zoning" Of Queensbury Town Code To Amend Zoning Map For a Portion Of Tax Map Parcel NO. 309.7-1-55,and BE IT FURTHER, RESOLVED, that the Town Board hereby authorizes and directs the Town Clerk to provide the public with at least 10 days'prior notice of the Public Hearing by causing a Notice of Public Hearing to be timely published in the Town's official newspaper and by posting the Notice of Public Hearing on the Town's web site and bulletin board at least 10 days before the date of the Public Hearing, and BE IT FURTHER, RESOLVED, that the Town Board authorizes and directs the Town Clerk to send copies of the Notice of Public Hearing, together with copies of the proposed zoning revisions, if required, to any public officials, agencies or municipalities, in accordance with any applicable State Laws or Town Code provisions, and BE IT FURTHER, RESOLVED, that the Town Board further authorizes and directs the Town Clerk to make a copy of the proposed zoning revisions (including a proposed revision to the Town's Zoning Map associated with the Zoning Code) available for public inspection during regular business hours of the Clerk's office, and BE IT FURTHER, RESOLVED, that the Town Board authorizes and directs the Town Supervisor, Town Clerk and/or Town Counsel to take such other actions and give such other notice as may be necessary in preparation for the Town Board to lawfully adopt proposed Local Law No.: of 2022. Duly adopted this 16th day of May, 2022, by the following vote: AYES NOES ABSENT: LOCAL LAWS\Chapter 179—Hudson Headwaters Western Ave—Office to Neighborhood Residential—6-13-2022 LOCAL LAW NO.: OF 2022 A LOCAL LAW TO AMEND CHAPTER 179 "ZONING" OF QUEENSBURY TOWN CODE TO AMEND ZONING MAP FOR A PORTION OF TAX MAP PARCEL NO. 309.7-1-55 BE. IT ENACTED BY THE TOWN BOARD OF THE TOWN OF QUEENSBURYAS FOLLOWS. SECTION 1. Queensbury Town Code Chapter 179, "Zoning," is hereby amended by amending the official Town Zoning Map to reflect a change of zoning district designation for a portion of tax map parcel No.: 309-7-1--55 located between Western Avenue, Holden Avenue, Nathan Street and Columbia Avenue from Office to Neighborhood Residential. SECTION 2. The Map appended to this Local Law is hereby adopted as the official Town Zoning Map of the Town of Queensbury and supersedes the previously adopted Town Zoning-Map. SECTION 3. The invalidity of any clause, sentence, paragraph or provision of this Local Law shall not invalidate any other clause, sentence,paragraph or part thereof. SECTION 4. All Local Laws or ordinances or parts of Local Laws or ordinances in conflict with any part of this Local Law are hereby repealed. SECTION 5. This Local Law shall take effect immediately upon filing in the Office of the New York Secretary of State as provided in New York Municipal Home Rule Law§27. Note: Language in bold.italics is new language to be added; Language with line 4awn fluough is old language to be deleted. 1 ! 1 Hudson Headwaters Proposed Rezoning Office to Neighborhood Res. 'µ' N W E L C Y Of' .."; Glen_"s Falls S Q 0 100 200 0 kl Feet °1 Map Produced byTOQGIS:5/2022 e _ . 1 I i I Area proposed to be a i rezoned from Office to r V Neighborhood Residential 4 F# ter• -° _, 1 . P I x, * SBL:309J-9r55 Y OWNER:•HUDSON HEADWATERS , r. y Revised Oct.2008 TOWN OF QUEENSBURY TOWN BOARD APPLICATION q'0 11 ,' PETITION FOR CHANGE OF ZONE . t���� N � Z 2ti�� �G? Petition No. (Office Use Only): ��.+;i 1 4vRI 1 �5 Applicant's Name: Hudson Headwaters Health Network Address: 9 Carey Road `°' zt dl �° CO Queensbury. NY 12804 To the Applicant: The Queensbury Planning Board will review this Petition and make recommendations to the Town Board. As part of this review, the Planning Board will consider the following questions and submit answers to the Town Board. As the applicant, you will have the option to provide answers for the Boards to consider. 1. What need is being met by the proposed change in zone or new zone? HHHN is in need of temporary housing for medical students and trainees, in an effort to better serve the,greater Queensbury region, and this zoning c i— an�ould allow them to build one duplex house in which they could accommodate pro essiona s in training at their tacilities. 2. What existing zones, if any, can meet the stated need? NQ'ghborhood Residential,the classification for which we ask a portion of this lot be aranted, would allow for the construction of a duplex house. 3. How is the proposed zone compatible with adjacent zones? While this parcel is bordered on all four sides by roads, there is a significant cluster of Neighborhood Residential lots to the west. 4. What physical characteristics of the site are suitable to the proposed zone? Portions of this property have been used for residential housing in the past, including the area requested for this zoning change. 5. How will the proposed zone affect public facilities? The proposed zone will have minimal impact public facilities, as existing and previous buildings were using the same facilities. 6. Why is the current zone classification not appropriate for the property in question? The current zone classification, office, is not appropriate for the portion of the property in question because it does not allow for duplex residential housing. 7. What are the environmental impacts of the proposed change? If any, this proposed change would have a positive impact on stormwater management, as any changes to the property will involve more advanced engineering than was done at the time of initial development. 1 Revised Oct.2008 8. How is the proposal compatible with the relevant portions of the Comprehensive Land Use Master Plan? This proposal is compatible with the relevant portions of the Comprehensive Land Use Master Plan because, should it com�ruition, it maximizes the best use o this land while a ancing enhancement ot the surrounding neig or oo . 9. How are the wider interests of the Community being served by this proposal? This proposed change is part of a greater plan to better serve the medical needs of the greater Queensbury area by providing incentive to medical professionals to train in our area. These questions are based on criteria used to review all zoning amendments. 2 Revised Oct.2008 Application - Petition for Change of Zone The applicant must submit a fee of $250 with the original & seventeen (17) copies of all documentation requested in this application to the Town Clerk's office. [Copies are distributed as follows: Town Board (5), Town Clerk(1), Town Counsel (1), Planning Board (9), File Copy (1), and Planning Staff(1). Petition No. (Office Use Only): Date Received by Town Clerk: Date Received by Planning Office: 1. Application For: (check where applicable) Amendment of Zoning Map X Amendment of Zoning Ordinance 2. Current Zoning: Office Proposed Zoning: Neighborhood Residential 3. Project Location: 28 Western Avenue South, Queensbury, NY 4. Tax Map ID: 309.7-1-55 5. Applicant: 9 Carey Road Address: Queensbury, NY 12804 Phone: 6. Applicant's Agent: gartlPtt, Pontiff. Stewart & Rhodes. P.C. Address: 1 Washinaton St Glens Falls, NY 12804 Phone: 518-792-2117 7. Property Owner: Hudson Headwaters Health Network Address: 9 Carey Road Queensbury, NY 12804 Phone: 8. Directions to Site: From 1-87N, take exit 18 and make a right on to Main Street. Continue until the intersection with Western Ave and turn left. Parcel is 1/4 mile ahead on left. 9. Statistics and Data on Property: a. Total Area: 103,500 sq. ft. or 2.38 acres b. Dimensions: Minimum Width: 450' Average Width: 450' Minimum Depth: 230' Average Depth: 230' 3 C Revised Oct.2008 Physical Irregularities (describe): None C. Existing use(s): include structures, outdoor uses, rights of way, easements, deeds and limitations to use of property: One two-story former office building, one one-story medical office building d. Adjacent uses within 400 feet: (state direction, location, use, zone & owner): Please refer to supplemental map e. State, County or Town property within 500 feet: None 10. A Map/Survey of the property to be rezoned must be submitted with the application; items A through H must be included on the plan and addressed in the submission A. Map of property at a scale of 1 inch =40 feet or less with scale, north arrow and topography. B. Boundaries of property with dimensions in feet, including zoning boundary. C. Identification of wetlands, watercourses or waterbodies on site. D. Location of any current structures on site, their exterior dimensions, use and setbacks. E. Location of any proposed easements and driveways. F. Location of existing public or private water and sewer facilities. G. Location of existing and proposed parking and loading facilities. H. Identification of uses (i.e. residential, commercial, industrial) on property within 500 feet. 11. If Petition is for an amendment to Zoning Ordinance, cite the section(s) to be changed, and wording to be substituted: 12. In support of this petition, the following statement is made: The action proposed in this petition, re-zoning a portion of the aforementioned parcel, would provide tremendous public benefit as it would allow HHHN to expand and grow its network of healthcare professionals in the area 13. The following documents are submitted herewith: Site map, map identifying uses within 500' 4 6I Z20 Appendix A State Environmental Quality Review Full Environmental Assessment Form Purpose: The Full Environmental Assessment Form (EAF)provides an orderly and comprehensive means for evaluating the potential environmental significance of a proposed action. The question of whether an action may be significant is not always easy to answer. Frequently,there are aspects of a project that are subjective or unmeasurable. It is also understood that those who determine significance may have little or no formal knowledge of the environment or may not be technically expert in environmental analysis. In addition,many who have knowledge in one particular area may not be aware of the broader concerns affecting the question of significance. The lead agency must use the Full EAF for Type I actions and may use it for Unlisted actions. The Full EAF consists of three parts and when completed it will serve as the determination of significance: Part I -Is completed by the project sponsor. Part 1 provides basic information including a description of the proposed action,proposed site location and its environmental resources. The information provided in Part 1 is later used by the reviewing agency to complete Parts 2 and 3. The questions in Part 1 are grouped in sections A-G: • Section A gathers information that identifies the project sponsor,the proposed action, and the proposed action's location. • Section B requests information about government approvals or funding. • Section C requests information about planning,zoning and community services. • Section D requests information about the proposed action. • Section E requests information about resources on or adjacent to the proposed site. • Section F provides the project sponsor the opportunity for supplying additional information including project elements that may avoid or reduce impacts. • Section G is where the certifying signature of the preparer is provided. Part 2 -Is completed by the lead agency. Part 2 is designed to help the lead agency inventory all potential resources that could be affected by a proposed action and to determine the potential size of the impact by providing a series of questions that can be answered using the information found in Part 1. To further assist the lead agency in completing Part 2,the form identifies the most relevant questions in Part 1 that will provide the information needed to answer the Part 2 question. Part 2 is designed to help a reviewer identify any element of a proposed project that may have a potentially significant adverse impact on the environment. Part 3 -Is completed by the lead agency. Part 2 questions where the impact has been identified as potentially moderate to large or where there is a need to explain why a particular element of the proposed action will not, or may, result in a significant adverse environmental impact should be explored in a series of written,well reasoned statements in Part 3. The discussion of impacts in Part 3 will serve as the supporting documentation for the determination of significance. Full Environmental Assessment Form Part 1 -Project and Setting Instructions for Completing Part 1 Part 1 is to be completed by the applicant or project sponsor. 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;indicate whether missing information does not exist, or is not reasonably available to the sponsor;and,when possible,generally describe work or studies which would be necessary to update or fully develop that information. Applicants/sponsors must complete all items in Sections A&B. In Sections C,D&E,most items contain an initial question that must be answered either"Yes"or"No". If the answer to the initial question is"Yes",complete the sub-questions that follow. If the answer to the initial question is"No",proceed to the next question. Section F allows the project sponsor to identify and attach any additional information. Section G requires the name and signature of the applicant or project sponsor to verify that the information contained in Part 1 is accurate and complete. A.Project and Applicant/Sponsor Information. Name of Action or Project: Project Location(describe,and attach a general location map): 2 Carlton Drive,Queensbury,NY Brief Description of Proposed Action(include purpose or need): This application is to change the zoning designation for a portion of the property at 28 Western Avenue from Office(0)to Neighborhood Residential(NR) to allow for the future construction of duplex housing units on said portion of the property which could accommodate medical professionals in training with Hudson Headwaters Health Network.Future development would,of course,be subject to site plan review. Name of Applicant/Sponsor: Telephone:518-761-0300 Hudson Headwaters Health Network E-Mail: teicher@hhhn.org Address:g Carey Road City/PO:Queensbury State:New York Zip Code:12804 Project Contact(if not same as sponsor;give name and title/role): Telephone:518-792-2117 Jonathan Lapper of Bartlett,Pontiff,Stewart&Rhodes,P.C. E-Mail: fcl@bpsrlaw.com Address: 1 Washington St City/PO: State: Zip Code: Glens Falls New York 12801 Property Owner (if not same as sponsor): Telephone: E-Mail: Address: City/PO: State: Zip Code: Page 1 of 13 B.Government Approvals B.Government Approvals,Funding,or Sponsorship. ("Funding"includes grants,loans,tax relief,and any other forms of financial assistance.) Government Entity If Yes:Identify Agency and Approval(s) Application Date Required (Actual or projected) a. City Counsel,Town Board, mYes❑No This project is subject to review and vote by the As soon as possible or Village Board of Trustees Queensbury Town Board b. City,Town or Village ❑YesmNo Planning Board or Commission c.City,Town or ❑YesmNo Village Zoning Board of Appeals d.Other local agencies ❑YesmNo e.County agencies ❑YesmNo f.Regional agencies ❑YesmNo g.State agencies ❑YesmNo h.Federal agencies ❑YesmNo i. Coastal Resources. i. Is the project site within a Coastal Area,or the waterfront area of a Designated Inland Waterway? ❑Yes mNo ii. Is the project site located in a community with an approved Local Waterfront Revitalization Program? ❑YesmNo iii. Is the project site within a Coastal Erosion Hazard Area? ❑YesmNo C.Planning and Zoning C.1.Planning and zoning actions. Will administrative or legislative adoption,or amendment of a plan,local law,ordinance,rule or regulation be the mYes❑No only approval(s)which must be granted to enable the proposed action to proceed? • If Yes,complete sections C,F and G. • If No,proceed to question C.2 and complete all remaining sections and questions in Part 1 C.2.Adopted land use plans. a.Do any municipally-adopted (city,town,village or county)comprehensive land use plan(s)include the site mYes❑No where the proposed action would be located? If Yes,does the comprehensive plan include specific recommendations for the site where the proposed action ❑YesmNo would be located? b. Is the site of the proposed action within any local or regional special planning district(for example: Greenway; ❑YesmNo Brownfield Opportunity Area(BOA);designated State or Federal heritage area;watershed management plan; or other?) If Yes,identify the plan(s): c. Is the proposed action located wholly or partially within an area listed in an adopted municipal open space plan, ❑YesmNo or an adopted municipal farmland protection plan? If Yes,identify the plan(s): Page 2 of 13 C.3. Zoning a. Is the site of the proposed action located in a municipality with an adopted zoning law or ordinance. ®Yes❑No If Yes,what is the zoning classification(s)including any applicable overlay district? Yes,this site is currently within a designated Office Zone b. Is the use permitted or allowed by a special or conditional use permit? ❑Yes®No c.Is a zoning change requested as part of the proposed action? ®Yes❑No If Yes, i. What is the proposed new zoning for the site? Neighborhood residential CA.Existing community services. a.In what school district is the project site located?Glens Falls City School District b.What police or other public protection forces serve the project site? Warren County Sheriffs,New York State Police c.Which fire protection and emergency medical services serve the project site? Queensbury Central Fire Department,West Glens Falls EMS d.What parks serve the project site? N/A D.Project Details D.1.Proposed and Potential Development a.What is the general nature of the proposed action(e.g.,residential,industrial,commercial,recreational;if mixed,include all components)? Changing the zoning of this parcel from Moderate Density Residential to Commercial Intensive b.a.Total acreage of the site of the proposed action? M acres b.Total acreage to be physically disturbed? 0.3 acres c.Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor? 2.3 acres c.Is the proposed action an expansion of an existing project or use? ®Yes❑No i. If Yes,what is the approximate percentage of the proposed expansion and identify the units(e.g.,acres,miles,housing units, square feet)? % 10 Units: 2 d.Is the proposed action a subdivision,or does it include a subdivision? ❑Yes ONo If Yes, i. Purpose or type of subdivision?(e.g.,residential,industrial,commercial;if mixed,specify types) ii. Is a cluster/conservation layout proposed? ❑Yes❑No iii.Number of lots proposed? iv. Minimum and maximum proposed lot sizes? Minimum Maximum e.Will the proposed action be constructed in multiple phases? ❑Yes®No i. If No,anticipated period of construction: 4 months ii. If Yes: • Total number of phases anticipated • Anticipated commencement date of phase 1 (including demolition) month year • Anticipated completion date of final phase month ____year • Generally describe connections or relationships among phases,including any contingencies where progress of one phase may determine timing or duration of future phases: Page 3 of 13 f.Does the project include new residential uses? ®Yes❑No If Yes,show numbers of units proposed. One Family Two Family Three Family Multiple Family f� our or more Initial Phase 1 At completion of all phases 1 g.Does the proposed action include new non-residential construction(including expansions)? ❑Yes®No If Yes, i.Total number of structures ii. Dimensions(in feet)of largest proposed structure: height; width; and length iii. Approximate extent of building space to be heated or cooled: square feet h.Does the proposed action include construction or other activities that will result in the impoundment of any ❑Yes®No liquids,such as creation of a water supply,reservoir,pond,lake,waste lagoon or other storage? If Yes, i.Purpose of the impoundment: ii. If a water impoundment,the principal source of the water: ❑ Ground water❑Surface water streams[]Other specify: iii. If other than water,identify the type of impounded/contained liquids and their source. iv. Approximate size of the proposed impoundment. Volume: million gallons;surface area: acres v. Dimensions of the proposed dam or impounding structure: height; length vi. Construction method/materials for the proposed dam or impounding structure(e.g.,earth fill,rock,wood,concrete): D.2. Project Operations a.Does the proposed action include any excavation,mining,or dredging,during construction,operations,or both? ❑Yes❑✓No (Not including general site preparation,grading or installation of utilities or foundations where all excavated materials will remain onsite) If Yes: i.What is the purpose of the excavation or dredging? ii. How much material(including rock,earth,sediments,etc.)is proposed to be removed from the site? • Volume(specify tons or cubic yards): • Over what duration of time? iii. Describe nature and characteristics of materials to be excavated or dredged,and plans to use,manage or dispose of them. iv. Will there be onsite dewatering or processing of excavated materials? []Yes[]No If yes,describe. v. What is the total area to be dredged or excavated? acres vi. What is the maximum area to be worked at any one time? acres vii.What would be the maximum depth of excavation or dredging? feet viii. Will the excavation require blasting? ❑Yes❑No ix. Summarize site reclamation goals and plan: b.Would the proposed action cause or result in alteration of,increase or decrease in size of,or encroachment ❑Yes❑✓No into any existing wetland,waterbody,shoreline,beach or adjacent area? If Yes: i. Identify the wetland or waterbody which would be affected(by name,water index number,wetland map number or geographic description): Page 4 of 13 ii. Describe how the proposed action would affect that waterbody or wetland,e.g.excavation,fill,placement of structures,or alteration of channels,banks and shorelines. Indicate extent of activities,alterations and additions in square feet or acres: iii.Will the proposed action cause or result in disturbance to bottom sediments? ❑Yes❑No If Yes,describe: iv.Will the proposed action cause or result in the destruction or removal of aquatic vegetation? ❑Yes❑No If Yes: • acres of aquatic vegetation proposed to be removed: • expected acreage of aquatic vegetation remaining after project completion: • purpose of proposed removal(e.g.beach clearing,invasive species control,boat access): • proposed method of plant removal: • if chemical/herbicide treatment will be used,specify product(s): v.Describe any proposed reclamation/mitigation following disturbance: c.Will the proposed action use,or create a new demand for water? ZYes❑No If Yes: i. Total anticipated water usage/demand per day: 440 gallons/day ii. Will the proposed action obtain water from an existing public water supply? WlYes❑No If Yes: • Name of district or service area: Town of Queensbury • Does the existing public water supply have capacity to serve the proposal? ®Yes❑No • Is the project site in the existing district? m Yes❑No • Is expansion of the district needed? ❑Yesm No • Do existing lines serve the project site? m Yes❑No iii. Will line extension within an existing district be necessary to supply the project? ❑Yes Flo If Yes: • Describe extensions or capacity expansions proposed to serve this project: • Source(s)of supply for the district: iv. Is a new water supply district or service area proposed to be formed to serve the project site? ❑Yes❑No If,Yes: • Applicant/sponsor for new district: • Date application submitted or anticipated: • Proposed source(s)of supply for new district: V. If a public water supply will not be used,describe plans to provide water supply for the project: vi.If water supply will be from wells(public or private),what is the maximum pumping capacity: gallons/minute. d.Will the proposed action generate liquid wastes? m Yes❑No If Yes: i. Total anticipated liquid waste generation per day: 440 gallons/day ii.Nature of liquid wastes to be generated(e.g.,sanitary wastewater,industrial;if combination,describe all components and approximate volumes or proportions of each): Sanitary iii. Will the proposed action use any existing public wastewater treatment facilities? El Yes ZNo If Yes: • Name of wastewater treatment plant to be used: • Name of district: • Does the existing wastewater treatment plant have capacity to serve the project? ❑Yes❑No • Is the project site in the existing district? ❑Yes❑No • Is expansion of the district needed? ❑Yes❑No Page 5 of 13 • Do existing sewer lines serve the project site? ❑Yes®No • Will a line extension within an existing district be necessary to serve the project? ❑Yes®No If Yes: • Describe extensions or capacity expansions proposed to serve this project: iv. Will a new wastewater(sewage)treatment district be formed to serve the project site? ❑Yes®No If Yes: • Applicant/sponsor for new district: • Date application submitted or anticipated: • What is the receiving water for the wastewater discharge? V. If public facilities will not be used,describe plans to provide wastewater treatment for the project,including specifying proposed receiving water(name and classification if surface discharge or describe subsurface disposal plans): vi. Describe any plans or designs to capture,recycle or reuse liquid waste: e.Will the proposed action disturb more than one acre and create stormwater runoff,either from new point ❑Yes®No sources(i.e.ditches,pipes,swales,curbs,gutters or other concentrated flows of stormwater)or non-point source(i.e.sheet flow)during construction or post construction? If Yes: i. How much impervious surface will the project create in relation to total size of project parcel? Square feet or acres(impervious surface) Square feet or acres(parcel size) ii. Describe types of new point sources. iii. Where will the stormwater runoff be directed(i.e.on-site stormwater management facility/structures,adjacent properties, groundwater,on-site surface water or off-site surface waters)? • If to surface waters,identify receiving water bodies or wetlands: • Will stormwater runoff flow to adjacent properties? ❑Yes❑No iv. Does the proposed plan minimize impervious surfaces,use pervious materials or collect and re-use stormwater? ❑Yes❑No f. Does the proposed action include,or will it use on-site,one or more sources of air emissions,including fuel ❑Yes®No combustion,waste incineration,or other processes or operations? If Yes,identify: i.Mobile sources during project operations(e.g.,heavy equipment,fleet or delivery vehicles) ii. Stationary sources during construction(e.g.,power generation,structural heating,batch plant,crushers) iii. Stationary sources during operations(e.g.,process emissions,large boilers,electric generation) g.Will any air emission sources named in D.2.f(above),require a NY State Air Registration,Air Facility Permit, ❑Yes®No or Federal Clean Air Act Title IV or Title V Permit? If Yes: i. Is the project site located in an Air quality non-attainment area? (Area routinely or periodically fails to meet ❑Yes❑No ambient air quality standards for all or some parts of the year) ii. In addition to emissions as calculated in the application,the project will generate: • Tons/year(short tons)of Carbon Dioxide(COZ) • Tons/year(short tons)of Nitrous Oxide(NZO) • Tons/year(short tons)of Perfluorocarbons(PFCs) • Tons/year(short tons)of Sulfur Hexafluoride(SF6) • Tons/year(short tons)of Carbon Dioxide equivalent of Hydroflourocarbons(HFCs) • Tons/year(short tons)of Hazardous Air Pollutants(HAPs) Page 6of13 h.Will the proposed action generate or emit methane(including,but not limited to,sewage treatment plants, ❑Yes®No landfills,composting facilities)? If Yes: i. Estimate methane generation in tons/year(metric): ii.Describe any methane capture,control or elimination measures included in project design(e.g.,combustion to generate heat or electricity,flaring): i.Will the proposed action result in the release of air pollutants from open-air operations or processes,such as ❑Yes®No quarry or landfill operations? If Yes:Describe operations and nature of emissions(e.g.,diesel exhaust,rock particulates/dust): j.Will the proposed action result in a substantial increase in traffic above present levels or generate substantial ❑YesRINo new demand for transportation facilities or services? If Yes: i. When is the peak traffic expected(Check all that apply): ❑Morning ❑Evening ❑Weekend ❑Randomly between hours of to ii. For commercial activities only,projected number of truck trips/day and type(e.g.,semi trailers and dump trucks): iii. Parking spaces: Existing Proposed Net increase/decrease iv.Does the proposed action include any shared use parking? ❑Yes❑No v If the proposed action includes any modification of existing roads,creation of new roads or change in existing access,describe: vi. Are public/private transportation service(s)or facilities available within'/z mile of the proposed site? ®Yes❑No vii Will the proposed action include access to public transportation or accommodations for use of hybrid,electric ❑Yes❑No or other alternative fueled vehicles? viii.Will the proposed action include plans for pedestrian or bicycle accommodations for connections to existing ❑Yes❑No pedestrian or bicycle routes? k.Will the proposed action(for commercial or industrial projects only)generate new or additional demand ❑Yes❑No for energy? If Yes: i. Estimate annual electricity demand during operation of the proposed action: ii. Anticipated sources/suppliers of electricity for the project(e.g.,on-site combustion,on-site renewable,via grid/local utility,or other): iii. Will the proposed action require a new,or an upgrade,to an existing substation? ❑Yes❑No 1.Hours of operation. Answer all items which apply. i. During Construction: ii. During Operations: • Monday-Friday: 7AM-7PM • Monday-Friday: Saturday: • Saturday: • Sunday: • Sunday: • Holidays: • Holidays: Page 7 of 13 m.Will the proposed action produce noise that will exceed existing ambient noise levels during construction, ❑Yes®No operation,or both? If yes: i. Provide details including sources,time of day and duration: ii. Will the proposed action remove existing natural barriers that could act as a noise barrier or screen? ❑Yes❑No Describe: n.Will the proposed action have outdoor lighting? ❑Yes®No If yes: i. Describe source(s), location(s),height of fixture(s),direction/aim,and proximity to nearest occupied structures: ii. Will proposed action remove existing natural barriers that could act as a light barrier or screen? ❑Yes❑No Describe: o.Does the proposed action have the potential to produce odors for more than-one hour per day? ❑Yes®No If Yes,describe possible sources,potential frequency and duration of odor emissions,and proximity to nearest occupied structures: p.Will the proposed action include any bulk storage of petroleum(combined capacity of over 1,100 gallons) ❑Yes®No or chemical products 185 gallons in above ground storage or any amount in underground storage? If Yes: i. Product(s)to be stored ii. Volume(s) per unit time (e.g.,month,year) iii. Generally,describe the proposed storage facilities: q.Will the proposed action(commercial,industrial and recreational projects only)use pesticides(i.e.,herbicides, ❑Yes ®No insecticides)during construction or operation? If Yes: i.Describe proposed trcatment(s): ii. Will the proposed action use Integrated Pest Management Practices? ❑ Yes ❑No r.Will the proposed action(commercial or industrial projects only)involve or require the management or disposal ❑ Yes ❑No of solid waste(excluding hazardous materials)? If Yes: i. Describe any solid waste(s)to be generated during construction or operation of the facility: • Construction: tons per (unit of time) • Operation: tons per (unit of time) ii. Describe any proposals for on-site minimization,recycling or reuse of materials to avoid disposal as solid waste: • Construction: • Operation: iii. Proposed disposal methods/facilities for solid waste generated on-site: • Construction: • Operation: Page 8 of 13 s.Does the proposed action include construction or modification of a solid waste management facility? ❑ Yes 0 No If Yes: i. Type of management or handling of waste proposed for the site(e.g.,recycling or transfer station,composting,landfill,or other disposal activities): ii. Anticipated rate of disposal/processing: • Tons/month,if transfer or other non-combustion/thermal treatment,or • Tons/hour,if combustion or thermal treatment iii. If landfill,anticipated site life: years t.Will the proposed action at the site involve the commercial generation,treatment,storage,or disposal of hazardous❑YesONo waste? If Yes: i.Name(s)of all hazardous wastes or constituents to be generated,handled or managed at facility: ii. Generally describe processes or activities involving hazardous wastes or constituents: iii. Specify amount to be handled or generated tons/month iv. Describe any proposals for on-site minimization,recycling or reuse of hazardous constituents: v. Will any hazardous wastes be disposed at an existing offsite hazardous waste facility? ❑Yes❑No If Yes:provide name and location of facility: If No: describe proposed management of any hazardous wastes which will not be sent to a hazardous waste facility: E.Site and Setting of Proposed Action E.I.Land uses on and surrounding the project site a.Existing land uses. i. Check all uses that occur on,adjoining and near the project site. ❑ Urban ❑ Industrial 0 Commercial 0 Residential(suburban) ❑ Rural(non-farm) ❑ Forest ❑ Agriculture ❑ Aquatic ❑ Other(specify): ii. If mix of uses,generally describe: b.Land uses and covertypes on the project site. Land use or Current Acreage After Change Covertype Acreage Project Completion (Acres+/-) • Roads,buildings,and other paved or impervious 0.32 0.32 0 surfaces • Forested 0 0 0 • Meadows,grasslands or brushlands(non- 0 0 0 agricultural,including abandoned agricultural) • Agricultural 0 0 0 (includes active orchards,field,greenhouse etc.) • Surface water features 0 0 0 (lakes,ponds,streams,rivers,etc.) • Wetlands(freshwater or tidal) 0 0 0 • Non-vegetated(bare rock,earth or fill) 0 0 0 • Other Describe: Page 9 of 13 c.Is the project site presently used by members of the community for public recreation? ❑YesE]No i. If Yes: explain: d.Are there any facilities serving children,the elderly,people with disabilities(e.g.,schools,hospitals,licensed ❑Yes❑No day care centers,or group homes)within 1500 feet of the project site? If Yes, i. Identify Facilities: The Glens Falls Center e.Does the project site contain an existing dam? ❑Yes®No If Yes: i. Dimensions of the dam and impoundment: • Dam height: feet • Dam length: feet • Surface area: acres • Volume impounded: gallons OR acre-feet ii.Dam's existing hazard classification: iii. Provide date and summarize results of last inspection: f.Has the project site ever been used as a municipal,commercial or industrial solid waste management facility, ❑YesONo or does the project site adjoin property which is now,or was at one time,used as a solid waste management facility? If Yes: i. Has the facility been formally closed? ❑Yes❑ No • If yes,cite sources/documentation: U. Describe the location of the project site relative to the boundaries of the solid waste management facility: W. Describe any development constraints due to the prior solid waste activities: g.Have hazardous wastes been generated,treated and/or disposed of at the site,or does the project site adjoin ❑YesONo property which is now or was at one time used to commercially treat,store and/or dispose of hazardous waste? If Yes: i. Describe waste(s)handled and waste management activities,including approximate time when activities occurred: h. Potential contamination history. Has there been a reported spill at the proposed project site,or have any ❑Yes0 No remedial actions been conducted at or adjacent to the proposed site? If Yes: i. Is any portion of the site listed on the NYSDEC Spills Incidents database or Environmental Site ❑Yes❑No Remediation database? Check all that apply: ❑ Yes—Spills Incidents database Provide DEC ID number(s): ❑ Yes—Environmental Site Remediation database Provide DEC ID number(s): ❑ Neither database ii. If site has been subject of RCRA corrective activities,describe control measures: iii. Is the project within 2000 feet of any site in the NYSDEC Environmental Site Remediation database? ®Yes❑No If yes,provide DEC ID number(s):557010 iv. If yes to(i), (ii)or(iii)above,describe current status of site(s): Page 10 of 13 v. Is the project site subject to an institutional control limiting property uses? ❑Yes®No • If yes,DEC site ID number: • Describe the type of institutional control(e.g.,deed restriction or easement): • Describe any use limitations: • Describe any engineering controls: • Will the project affect the institutional or engineering controls in place? ❑Yes❑No • Explain: E.2. Natural Resources On or Near Project Site a.What is the average depth to bedrock on the project site? s+feet b.Are there bedrock outcroppings on the project site? ❑YesZNo If Yes,what proportion of the site is comprised of bedrock outcroppings? % c.Predominant soil type(s)present on project site: Well drained sands 100 % a�0 d.What is the average depth to the water table on the project site? Average: 6+ feet e.Drainage status of project site soils:0 Well Drained: 100%of site ❑ Moderately Well Drained: %of site ❑ Poorly Drained %of site f.Approximate proportion of proposed action site with slopes: ® 0-10%: (a%of site ❑ 10-15%: %of site ❑ 15%or greater: %of site g.Are there any unique geologic features on the project site? ❑YesONo If Yes,describe: h.Surface water features. i. Does any portion of the project site contain wetlands or other waterbodies(including streams,rivers, ❑Yes®No ponds or lakes)? H. Do any wetlands or other waterbodies adjoin the project site? ❑YesZNo If Yes to either i or ii,continue. If No,skip to E.2.i. iii. Are any of the wetlands or waterbodies within or adjoining the project site regulated by any federal, ❑Yes ZNo state or local agency? iv. For each identified regulated wetland and waterbody on the project site,provide the following information: • Streams: Name Classification • Lakes or Ponds: Name Classification Wetlands: Name Approximate Size • Wetland No.(if regulated by DEC) v. Are any of the above water bodies listed in the most recent compilation of NYS water quality-impaired ❑Yes Zlo waterbodies? If yes,name of impaired water body/bodies and basis for listing as impaired: i.Is the project site in a designated Floodway? ❑YesZNo j.Is the project site in the 100-year Floodplain? ❑YesZNo k.Is the project site in the 500-year Floodplain? ❑YesZNo 1.Is the project site located over,or immediately adjoining,a primary,principal or sole source aquifer? DYes❑No If Yes: i.Name of aquifer:Principal Aquifer Page 11 of 13 m. Identify the predominant wildlife species that occupy or use the project site: n.Does the project site contain a designated significant natural community? ❑YesONo If Yes: i. Describe the habitat/community(composition,function,and basis for designation): ii. Source(s)of description or evaluation: iii. Extent of community/habitat: • Currently: acres • Following completion of project as proposed: acres • Gain or loss(indicate+or-): acres o.Does project site contain any species of plant or animal that is listed by the federal government or NYS as ❑YesZNo endangered or threatened,or does it contain any areas identified as habitat for an endangered or threatened species? If Yes: i. Species and listing(endangered or threatened): p. Does the project site contain any species of plant or animal that is listed by NYS as rare,or as a species of ❑YesW]No special concern? If Yes: i. Species and listing: q.Is the project site or adjoining area currently used for hunting,trapping,fishing or shell fishing? ❑YesONo If yes,give a brief description of how the proposed action may affect that use: E.3. Designated Public Resources On or Near Project Site a.Is the project site,or any portion of it,located in a designated agricultural district certified pursuant to ❑YesZNo Agriculture and Markets Law,Article 25-AA,Section 303 and 304? If Yes, provide county plus district name/number: b.Are agricultural lands consisting of highly productive soils present? ❑YesZNo i. If Yes:acreage(s)on project site? ii. Source(s)of soil rating(s): c. Does the project site contain all or part of,or is it substantially contiguous to,a registered National ❑Yes❑✓No Natural Landmark? If Yes: i. Nature of the natural landmark: ❑Biological Community ❑ Geological Feature ii. Provide brief description of landmark,including values behind designation and approximate size/extent: d.Is the project site located in or does it adjoin a state listed Critical Environmental Area? ❑YesONo If Yes: i. CEA name: ii. Basis for designation: iii. Designating agency and date: Page 12 of 13 e.Does the project site contain,or is it substantially contiguous to,a building,archaeological site,or district ❑Yes®No which is listed on the National or State Register of Historic Places,or that has been determined by the Commissioner of the NYS Office of Parks,Recreation and Historic Preservation to be eligible for listing on the State Register of Historic Places? If Yes: i.Nature of historic/archaeological resource: ❑Archaeological Site ❑Historic Building or District ii.Name: iii.Brief description of attributes on which listing is based: f.Is the project site,or any portion of it,located in or adjacent to an area designated as sensitive for ®Yes❑No archaeological sites on the NY State Historic Preservation Office(SHPO)archaeological site inventory? g.Have additional archaeological or historic site(s)or resources been identified on the project site? ❑Yes®No If Yes: 1.Describe possible resource(s): ii.Basis for identification: h.Is the project site within fives miles of any officially designated and publicly accessible federal,state,or local ❑Yes®No scenic or aesthetic resource? If Yes: i.Identify resource: U. Nature of,or basis for,designation(e.g.,established highway overlook,state or local park,state historic trail or scenic byway, etc.): iii.Distance between project and resource: miles. i. Is the project site located within a designated river corridor under the Wild,Scenic and Recreational Rivers ❑Yes®No Program 6 NYCRR 666? If Yes: i. Identify the name of the river and its designation: ii. Is the activity consistent with development restrictions contained in 6NYCRR Part 666? ❑Yes❑No F.Additional Information Attach any additional information which may be needed to clarify your project. If you have identified any adverse impacts which could be associated with your proposal,please describe those impacts plus any measures which you propose to avoid or minimize them. G. Verification I certify that the information provided is true to the best of my knowledge. Applicant/Sponsor Name Hudson Headwaters Health Network Date June 28,2021 7\ Signatur Title C i PRINT FARM rage 13 of 13 EAF Mapper Summary Report Sunday, June 27, 2021 2:14 PM Disclaimer: The EAF Mapper is a screening tool intended to assist �309�7tt,�=iQg�►7q g `,�309c7.�5=3q project sponsors and reviewing agencies in preparing an environmental _ � assessment form(EAF).Not all questions asked in the EAF are 309,.7-2-4a 349 7 10=5�8309: 0 '4.109 7 5=1 I answered by the EAF Mapper.Additional information on any EAF 309 0= 8 309.7-2;28 11 S t .. I question can be obtained b consulting the EAF Workbooks. Although •30.9,7=t0-293©9. ,J!0-2d ti � � �- y y 9 9 30,9;:7 2=42..._ ,; - 309 7-5'-15 I 7-309'7?LO=;192 the EAF Mapper provides the most up-to-date digital data available to 309:6=[;'3509 7c2-29309 7 2=36 309 7 2 I7 - I DEC,you may also need to contact local or other data sources in order I` -- 30i9 d 'I©t1215-11-18 to obtain data not provided by the Mapper.Digital data is not a ,- . 309 7.1,0 20_�309.73Q9 6 t-I309 7,-2 3E rL� substitute for agency determinations. _ � ti - 3'b 9 7-1;0 25 1 ��C ° _Si } 309:7 2 32� 1 309 7-2740_r� 309 T-10'2't---�309'7-5=2a 3 9 6 138 2� L ti -.. t ti q -----.. K ••Z.t SL- I FS 30�7 7 1 58 309 7 1-35 309 7 1 60 1 309:7=10 �-r ' 309.E:1-45 I - 9 7 10 3'l 309Z-.l-34 fl ad a fantrcalOtt - 0971 .3306140 309 7-1,, 309 : 2,'-'18Se I - 9? IJ' =30 6129 30 1 r Glens Falls __309 6-IC I. U i 09+ i -� 30 :6 d.27 309 t IQ-Z' I Y Toronto_ � 309 7 1 32 �30 7 5 y 5 h I tx- 309T10,,=33 r� "y3©9 1r42ti1 3,09 ! 1 5330 .- 9_ 1 309!7-421� �� ; 13( Pccf t r 309 6 14=1 ,m m- {' e I i 1 rr Afb,rr, 309 6 143 1'30p 7=1 17.3,09 7 1�-6 09 7 t•5 309 7='19�10 i f q I Bostcn L��—rlIr(tity9 ra a i xl:- �309 7 1 2rY l YT� oi 1 309 7 2630t9 6 �'309 6 ft-,t309 7 I28 1309 d�L=1:6309 78'� { r - 309.7:1=3, 309:i=t 0-5309 7• l?3 3 349.E 9.-2 309_7_:1 25309_7 t5 ti l x y ' , �VevrYork � i d '309 7-10-3 5 3,09:7;T 2 2 C 'i.•i, J r „ ;l: i u r 30.9I l 2 24 _ 309:7 10 �-,. c�R+tb.agh - - 'aimil7,.l S ,5:11 �n»7I�,.IN�RE�T(f1T�FT C aIt,'EESS'�i•I p.�1ETI�EsIi r a.(M 1i0lt i� 2'Esl �1.IEf lT ilrkt�It Esn Jaj�an,t lEll;`EsinTCanal(Han�l Konc(i;Esti t sri,ffltailanctl, t11�r ;I l ni�a y5 c f', t Oltt IS Itfis33aficltl��fflSL�'s�t, onliafun f c( nc�j?aiSti�ttllal�c�tttiil� I�I ieGIsusel �_C�171111i.IflltV LB.i.j [Coastal or Waterfront Area] TNo B.i.ii [Local Waterfront Revitalization Area] No - s C.2.b. [Special Planning District] i Digital mapping data are not available or are incomplete. Refer to EAF L�_ -- ---- l Workbook. - ----- - ------------- E.1.h [DEC Spills or Remediation Site- Digital mapping data are not available or are incomplete. Refer to EAF Potential Contamination History] _____!Workbook - E.1.h.i [DEC Spills or Remediation Site- Digital mapping data are not available or are incomplete. Refer to EAF Listed] — - _-- Workbook. __ E.1.h.i [DEC Spills or Remediation Site- Digital mapping data are not available or are incomplete Refer to EAF Environmental Site Remediation Database] I Workbook. E.1.h.iii [Within 2,000'of DEC Remediation Yes jSite] -- — --- --- -------- --------- -- --- -- �E.1.h.iii [Within 2,000' of DEC Remediation 557010 ;Site- DEC ID] IiE.2.g [Unique Geologic Features]- -------No ---1-- -------------------------- --------- E.2.h.i [Surface Water Features] INo E.2.h.ii [Surface Water Features] No 'E.2.h.iii [Surface Water Features] -------JNo --- - ---------------------_-'-^-- --------_' iE.2 vh [Impaired Water Bodies]^ —No v E.2.i. [Floodway] `- _ - - Digital mapping data are not available or are incomplete. Refer to EAF -` Workbook. E.2.j. [100 Year Floodplain] Digital mapping data are not available or are incomplete. Refer to EAF Workbook. E.2.k. [500 Year Floodplain] Digital mapping data are not available or are incomplete. Refer to EAF lWorkbook. E.2.1. [Aquifers] iYes E.2.1. [Aquifer Names] Principal Aquifer Full Environmental Assessment Form - EAF Mapper Summary Report , E.2.o. [Endangered or Threatened Species] No E.2.p. [Rare Plants or Animals] No E.3.a. [Agricultural District] No �E.3.c, [National Natural Landmark] No E.3.d [Critical Environmental Area] No E.3.e. [National or State Register of Historic Digital mapping data are not available or are incomplete. Refer to EAF Places or State Eligible Sites] Workbook. E.3.f. [Archeological Sites] Yes E.3.i. [Designated River Corridor] No Full Environmental Assessment Form - EAF Mapper Summary Report , Full Environmental Assessment Form Part 2-Identification of Potential Project Impacts Part 2 is to be completed by the lead agency. Part 2 is designed to help the lead agency inventory all potential resources that could be affected by a proposed project or action. We recognize that the lead agency's reviewer(s)will not necessarily be environmental professionals. So,the questions are designed to walk a reviewer through the assessment process by providing a series of questions that can be answered using the information found in Part 1. To further assist the lead agency in completing Part 2,the form identifies the most relevant questions in Part 1 that will provide the information needed to answer the Part 2 question. When Part 2 is completed,the lead agency will have identified the relevant environmental areas that may be impacted by the proposed activity. If the lead agency is a state agency and the action is in any Coastal Area,complete the Coastal Assessment Form before proceeding with this assessment. Tips for completing Part 2: • Review all of the information provided in Part 1. • Review any application,maps,supporting materials and the Full EAF Workbook. • Answer each of the 18 questions in Part 2. • If you answer"Yes"to a numbered question,please complete all the questions that follow in that section. • If you answer"No"to a numbered question,move on to the next numbered question. • Check appropriate column to indicate the anticipated size of the impact. • Proposed projects that would exceed a numeric threshold contained in a question should result in the reviewing agency checking the box"Moderate to large impact may occur." • The reviewer is not expected to be an expert in environmental analysis. • If you are not sure or undecided about the size of an impact,it mayhelp to review the sub-questions for the general question and consult the workbook. • When answering a question consider all components of the proposed activity,that is,the"whole action". • Consider the possibility for long-term and cumulative impacts as well as direct impacts. • Answer the question in a reasonable manner considering the scale and context of the project. 1. Impact on Land Proposed action may involve construction on,or physical alteration of, ❑NO ❑ YES the land surface of the proposed site. (See Part 1.D.1) I "Yes", answer questions a- '. I "No", move on to Section 2. Relevant No,or Moderate Part I small to large Question(s) impact impact may may occur occur a.The proposed action may involve construction on land where depth to water table is E2d ❑ ❑ less than 3 feet. b.The proposed action may involve construction on slopes of 15%or greater. E2f ❑ ❑ c.The proposed action may involve construction on land where bedrock is exposed,or E2a ❑ ❑ generally within 5 feet of existing ground surface. d.The proposed action may involve the excavation and removal of more than 1,000 tons D2a ❑ ❑ of natural material. e.The proposed action may involve construction that continues for more than one year Dle ❑ ❑ or in multiple phases. f.The proposed action may result in increased erosion,whether from physical D2e,D2q ❑ ❑ disturbance or vegetation removal(including from treatment by herbicides). g.The proposed action is,or may be,located within a Coastal Erosion hazard area. BE ❑ ❑ h.Other impacts: ❑ ❑ Page 1 of 10 2. Impact on Geological Features The proposed action may result in the modification or destruction of,or inhibit access to,any unique or unusual land forms on the site(e.g.,cliffs,dunes, EX NO ❑ YES minerals,fossils, caves). (See Part 1.E.2.g) I "Yes", answer questions a-c. If"No", move on to Section 3. Relevant No,or Moderate Part I small to large Question(s) impact impact may may occur occur a.Identify the specific land form(s)attached: E2g ❑ ❑ b.The proposed action may affect or is adjacent to a geological feature listed as a E3c ❑ ❑ registered National Natural Landmark. Specific feature: c. Other impacts: ❑ ❑ 3. Impacts on Surface Water The proposed action may affect one or more wetlands or other surface water Ll NO ❑ YES bodies(e.g.,streams,rivers,ponds or lakes). (See Part 1.D.2,E.2.h) I "Yes", answer questions a-1. I "No", move on to Section 4. Relevant No,or Moderate Part I small to large --_ Question(s) impact impact may =---- may occur occur a.The proposed action may create a new water body. 132b,Dlh ❑ ❑ b.The proposed action may result in an increase or decrease of over 10%or more than a D2b ❑ ❑ 10 acre increase or decrease in the surface area of any body of water. c.The proposed action may involve dredging more than 100 cubic yards of material D2a ❑ ❑ from a wetland or water body. d.The proposed action may involve construction within or adjoining a freshwater or E2h ❑ ❑ tidal wetland,or in the bed or banks of any other water body. e.The proposed action may create turbidity in a waterbody,either from upland erosion, D2a,D2h ❑ ❑ runoff or by disturbing bottom sediments. f.The proposed action may include construction of one or more intake(s)for withdrawal 132c ❑ ❑ of water from surface water. g.The proposed action may include construction of one or more outfall(s)for discharge D2d ❑ ❑ of wastewater to surface water(s). h.The proposed action may cause soil erosion,or otherwise create a source of D2e ❑ ❑ stormwater discharge that may lead to siltation or other degradation of receiving water bodies. i.The proposed action may affect the water quality of any water bodies within or E2h ❑ ❑ downstream of the site of the proposed action. j.The proposed action may involve the application of pesticides or herbicides in or D2q,E2h ❑ ❑ around any water body. F The proposed action may require the construction of new,or expansion of existing, DIa,D2d ❑ ❑ wastewater treatment facilities. Page 2 of 10 1.Other impacts: 4. Impact on groundwater The proposed action may result in new or additional use of ground water, or ®NO ❑ YES may have the potential to introduce contaminants to ground water or an aquifer. (See Part 1.D.2.a,D.2.c,D.2.d,D.2.p,D.2.q,D.2.t) If"Yes", answer questions a-h. If"No", move on to Section 5. Relevant No,or Moderate Part I small to large Question(s) impact impact may = may occur occur a.The proposed action may require new water supply wells,or create additional demand D2c ❑ ❑ on supplies from existing water supply wells. b.Water supply demand from the proposed action may exceed safe and sustainable D2c ❑ ❑ withdrawal capacity rate of the local supply or aquifer. Cite Source: c.The proposed action may allow or result in residential uses in areas without water and D1 a,D2c ❑ ❑ sewer services. d.The proposed action may include or require wastewater discharged to groundwater. D2d,E21 ° ° e.The proposed action may result in the construction of water supply wells in locations 132c,Elf, ❑ ❑ where groundwater is,or is suspected to be,contaminated. Elg,Elh f.The proposed action may require the bulk storage of petroleum or chemical products D2p,E21 ❑ ❑ over ground water or an aquifer. g.The proposed action may involve the commercial application of pesticides within 100 E2h,D2q, ❑ ❑ feet of potable drinking water or irrigation sources. E21,D2c h. Other impacts: ❑ ❑ 5. Impact on Flooding The proposed action may result in development on lands subject to flooding. NO ❑ YES (See Part 1.E.2) I "Yes' answer questions a-g. I "No", move on to Section 6. `- Relevant No,or Moderate Part I small to large Question(s) impact impact may may occur occur a.The proposed action may result in development in a designated floodway. Eli ❑ ❑ b.The proposed action may result in development within a 100 year floodplain. E2j ❑ ❑ c.The proposed action may result in development within a 500 year floodplain. E2k ❑ ❑ d.The proposed action may result in,or require,modification of existing drainage D2b,D2e ❑ ❑ patterns. e.The proposed action may change flood water flows that contribute to flooding. D2b,Eli, ❑ ❑ E2',E2k f.If there is a dam located on the site of the proposed action,the dam has failed to meet Ele ❑ ❑ one or more safety criteria on its most recent inspection. Page 3 of 10 g.Other impacts: ❑ ❑ 6. Impacts on Air The proposed action may include a state regulated air emission source. V)NO ❑ YES (See Part 1.D.2.f.,D,2,h,D.2.g) If"Yes", answer questions a-f. If"No", move on to Section 7. Relevant No,or Moderate Part I small to large Question(s) impact impact may may occur occur a.If the proposed action requires federal or state air emission permits,the action may also emit one or more greenhouse gases at or above the following levels: i. More than 1000 tons/year of carbon dioxide(CO2) D2g ❑ ❑ ii. More than 3.5 tons/year of nitrous oxide(N20) D2g ❑ ❑ iii.More than 1000 tons/year of carbon equivalent of perfluorocarbons(PFCs) D2g ❑ ❑ iv.More than.045 tons/year of sulfur hexafluoride(SF6) D2g ❑ ❑ v. More than 1000 tons/year of carbon dioxide equivalent of D2g ❑ ❑ hydrochloroflurocarbons(HCFCs)emissions vi.43 tons/year or more of methane D2h ❑ ❑ b.The proposed action may generate 10 tons/year or more of any one designated D2g ❑ ❑ hazardous air pollutant,or 25 tons/year or more of any combination of such hazardous air pollutants. c.The proposed action may require a state air registration,or may produce an emissions D2f,D2g ❑ ❑ rate of total contaminants that may exceed 5 lbs.per hour,or may include a heat source capable of producing more than 10 million BTU's per hour. d.The proposed action may reach 50%of any two or more of the thresholds in"a" Dlg,D2k ❑ ❑ through"c",above. e.The proposed action may result in the combustion or thermal treatment of more than 1 D2s ❑ ❑ ton of refuse per hour. f.Other impacts: ❑ ❑ 7. Impact on Plants and Animals The proposed action may result in a loss of flora or fauna. (See Part 1.E.2.m:q.) M NO ❑YES I "Yes", answer questions a-j. I "No", move on to Section 8. - Relevant No,or Moderate Part I small to large Question(s) impact impact may may occur occur a.The proposed action may cause reduction in population or loss of individuals of any E20 ❑ ❑ threatened or endangered species,as listed by New York State or the Federal government,that use the site,or are found on,over,or near the site. b.The proposed action may result in a reduction or degradation of any habitat used by E2o ❑ ❑ any rare,threatened or endangered species,as listed by New York State or the federal government. c.The proposed action may cause reduction in population,or loss of individuals,of any E2p ❑ ❑ species of special concern or conservation need,as listed by New York State or the Federal government,that use the site,or are found on,over,or near the site. d)The proposed action may result in a reduction or degradation of any habitat used by E2p ❑ ❑ any species of special concern and conservation need,as listed by New York State or the Federal government. Page 4 of 10 e.The proposed action may diminish the capacity of a registered National Natural E3c ❑ ❑ Landmark to support the biological community it was established to protect. f.The proposed action may result in the removal of,or ground disturbance in,any E2n ❑ ❑ portion of a designated significant natural community. Source: g.The proposed action may substantially interfere with nestingibreeding,foraging,or E2m ❑ ❑ over-wintering habitat for the predominant species that occupy or use the project site. h.The proposed action requires the conversion of more than 10 acres of forest, Elb ❑ ❑ grassland or any other regionally or locally important habitat. Habitat type&information source: i.Proposed action(commercial,industrial or recreational projects,only)involves use of D2q ❑ ❑ herbicides or pesticides. j.Other impacts: ❑ ❑ 8. Impact on Agricultural Resources The proposed action may impact agricultural resources. (See Part 1.E.3.a.and b.) ®NO ❑ YES I "Yes", answer questions a-h. I "No", move on to Section 9. Relevant No,or Moderate Part I small to large Question(s) impact impact may may occur occur a.The proposed action may impact soil classified within soil group 1 through 4 of the Etc,E3b ❑ ❑ NYS Land Classification System. b.The proposed action may sever,cross or otherwise limit access to agricultural land Ela,Elb ❑ ❑ (includes cropland,hayfields,pasture,vineyard,orchard,etc). c.The proposed action may result in the excavation or compaction of the soil profile of E3b ❑ ❑ active agricultural land. d.The proposed action may irreversibly convert agricultural land to non-agricultural Elb,E3a ❑ ❑ uses,either more than 2.5 acres if located in an Agricultural District,or more than 10 acres if not within an Agricultural District. e.The proposed action may disrupt or prevent installation of an agricultural land El a,Elb ❑ ❑ management system. f.The proposed action may result,directly or indirectly,in increased development C2c,C3, ❑ ❑ potential or pressure on farmland. D2c,D2d g.The proposed project is not consistent with the adopted municipal Farmland C2c ❑ ❑ Protection Plan. h.Other impacts: ❑ ❑ 9. Impact on Aesthetic Resources The land use of the proposed action are obviously different from,or are in ®NO ❑ YES sharp contrast to,current land use patterns between the proposed project and a scenic or aesthetic resource. (Part 1.E.La,E.Lb,E.31.) I "Yes", answer questions a-g, I "No", o to Section 10. - Relevant No,or Moderate Part I small to large Question(s) impact impact may may occur occur Page 5 of 10 a.Proposed action may be visible from any officially designated federal,state,or local E3h ❑ ❑ scenic or aesthetic resource. b.The proposed action may result in the obstruction,elimination or significant E3h,C2b ❑ ❑ screening of one or more officially designated scenic views. c.The proposed action may be visible from publicly accessible vantage points: E3h i.Seasonally(e.g.,screened by summer foliage,but visible during other seasons) ❑ ❑ ii.Year round ❑ ❑ d.The situation or activity in which viewers are engaged while viewing the proposed E3h action is: E2q, i. Routine travel by residents,including travel to and from work ❑ ❑ ii.Recreational or tourism based activities Elc ❑ ❑ e.The proposed action may cause a diminishment of the public enjoyment and E3h ❑ ❑ appreciation of the designated aesthetic resource. f. There are similar projects visible within the following distance of the proposed DI a,El a, ❑ ❑ project: Dlf,Dlg 0-1/2 mile '/Z-3 mile 3-5 mile 5+ mile g.Other impacts: ❑ ❑ 10. Impact on Historic and Archeological Resources The proposed action may occur in or adjacent to a historic or archaeological El NO ❑YES resource. (Part 1.E.3.e,f. and g.) If"Yes", answer questions a-e. If"No", go to Section 11. Relevant No,or Moderate Part I small to large Question(s) impact impact may _ may occur occur a.The proposed action may occur wholly or partially within,or substantially contiguous E3e ❑ ❑ to,any buildings,archaeological site or district which is listed on or has been nominated by the NYS Board of Historic Preservation for inclusion on the State or National Register of Historic Places. b.The proposed action may occur wholly or partially within,or substantially contiguous E3f ❑ ❑ to,an area designated as sensitive for archaeological sites on the NY State Historic Preservation Office(SHPO)archaeological site inventory. c.The proposed action may occur wholly or partially within,or substantially contiguous E3g ❑ ❑ to,an archaeological site not included on the NY SHPO inventory. Source: d.Other impacts: ❑ ❑ e.If any of the above(a-d)are answered"Yes",continue with the following questions to help support conclusions in Part 3: i. The proposed action may result in the destruction or alteration of all or part E3e,E3g, ❑ ❑ of the site or property. E3f ii. The proposed action may result in the alteration of the property's setting or E3e,E3f, ❑ ❑ E3g,Ela, Page 6of10 integrity. El b E3e,EH, ❑ ❑ iii. The proposed action may result in the introduction of visual elements which E3g,E3h, are out of character with the site or property,or may alter its setting. C2,C3 11. Impact on Open Space and Recreation The proposed action may result in a loss of recreational opportunities or a M NO ❑YES reduction of an open space resource as designated in any adopted municipal open space plan. (See Part 1.C.2.c,E.Le.,E.2.q.) If"Yes answer questions a-e. I "No", go to Section 12. Relevant No,or Moderate Part I small to large Question(s) impact impact may may occur occur a.The proposed action may result in an impairment of natural functions,or"ecosystem D2e,Elb ❑ ❑ services",provided by an undeveloped area,including but not limited to stormwater E2h, storage,nutrient cycling,wildlife habitat. Elm,Ego, E2n,E2 b.The proposed action may result in the loss of a current or future recreational resource. C2a,Elc, ❑ ❑ C2c,E2 c.The proposed action may eliminate open space or recreational resource in an area C2a,C2c o ❑ with few such resources. Elc,E2q d.The proposed action may result in loss of an area now used informally by the C2c,E1 c ❑ ❑ community as an open space resource. e. Other impacts: ❑ ❑ 12. Impact on Critical Environmental Areas The proposed action may be located within or adjacent to a critical M NO ❑YES environmental area(CEA). (See Part 1.E.3.d) If"Yes", answer questions a-c. I "No", go to Section 13. _= Relevant No,or Moderate _= Part I small to large Question(s) impact impact may may occur occur a.The proposed action may result in a reduction in the quantity of the resource or E3d ❑ ❑ characteristic which was the basis for designation of the CEA. b.The proposed action may result in a reduction in the quality of the resource or E3d ❑ ❑ characteristic which was the basis for designation of the CEA. c.Other impacts: ❑ ❑ 13. Impact on Transportation . The proposed action may result in a change to existing transportation systems. ®NO ❑YES (See Part 1.D.2 j) I "Yes", answer questions a-g. I "No", go to Section 14. Relevant No,or Moderate Part I small to large Question(s) impact impact may may occur occur a.Projected traffic increase may exceed capacity of existing road network. D2j ❑ ❑ Page 7 of 10 b.The proposed action may result in the construction of paved parking area for 500 or D2j ❑ ❑ more vehicles. c.The proposed action will degrade existing transit access. D2j ❑ ❑ d.The proposed action will degrade existing pedestrian or bicycle accommodations. D2j ❑ ❑ f.The proposed action may alter the present pattern of movement of people or goods. D2j ❑ ❑ g.Other impacts: ❑ ❑ 14. Impact on Energy The proposed action may cause an increase in the use of any form of energy. ®NO ❑ YES (See Part 1.13.21) I "Yes", answer questions a-e. I "No", o to Section 15. Relevant No,or Moderate _ Part I small to large Question(s) impact impact may may occur occur a.The proposed action will require a new,or an upgrade to an existing,substation. D2k ❑ ❑ b.The proposed action will require the creation or extension of an energy transmission D I f, ❑ ❑ or supply system to serve more than 50 single or two-family residences or to serve a D 1 q,D2k commercial or industrial use. c.The proposed action may utilize more than 2,500 MWhrs per year of electricity. D2k ❑ ❑ d.The proposed action may involve heating and/or cooling of more than 100,000 square D1 g ❑ ❑ feet of building area when completed. e.Other Impacts: 15. Impact on Noise,Odor,and Light The proposed action may result in an increase in noise, odors,or outdoor lighting. ®NO ❑YES (See Part 1.D.2.m.,n.,and o.) I "Yes", answer questions a-f I "No", o to Section 16. Relevant No,or Moderate _ Part I small to large Question(s) impact impact may may occur occur a.The proposed action may produce sound above noise levels established by local D2m ❑ ❑ regulation. b.The proposed action may result in blasting within 1,500 feet of any residence, D2m,Eld ❑ ❑ hospital,school,licensed day care center,or nursing home. C.The proposed action may result in routine odors for more than one hour per day. D2o ❑ ❑ d.The proposed action may result in light shining onto adjoining properties. D2n ❑ ❑ e.The proposed action may result in lighting creating sky-glow brighter than existing D2n,Ela ❑ ❑ area conditions. f.Other impacts: ❑ ❑ 16. Impact on Human Health The proposed action may have an impact on human health from exposure 2 NO ❑YES Page 8 of 10 to new or existing sources of contaminants. (See Part 1.D.2.q.,E.1.d.f. g.and h.) 1 "Yes", answer questions a-m. I "No", o to Section 17. Relevant No,or Moderate Part I small to large Question(s) impact impact may may cccur occur a.The proposed action is located within 1500 feet of a school,hospital,licensed day EI d ❑ ❑ care center,group home,nursing home or retirement community. b.The site of the proposed action is currently undergoing remediation. Elg,Elh ❑ ❑ c.There is a completed emergency spill remediation,or a completed environmental site Elg,Elh ❑ ❑ remediation on,or adjacent to,the site of the proposed action. d.The site of the action is subject to an institutional control limiting the use of the Elg,Elh ❑ ❑ property(e.g.easement,deed restriction) e.The proposed action may affect institutional control measures that were put in place Elg,Elh ❑ ❑ to ensure that the site remains protective of the environment and human health. f.The proposed action has adequate control measures in place to ensure that future 132t ❑ ❑ generation,treatment and/or disposal of hazardous wastes will be protective of the environment and human health. g.The proposed action involves construction or modification of a solid waste D2q,Elf ❑ ❑ management facility. h.The proposed action may result in the unearthing of solid or hazardous waste. D2q,Elf ❑ ❑ i.The proposed action may result in an increase in the rate of disposal,or processing,of 132r,D2s ❑ ❑ solid waste. j.The proposed action may result in excavation or other disturbance within 2000 feet of Elf,Elg ❑ ❑ a site used for the disposal of solid or hazardous waste. Elh k.The proposed action may result in the migration of explosive gases from a landfill Elf,Elg ❑ ❑ site to adjacent off site structures. 1.The proposed action may result in the release of contaminated leachate from the 132s,Elf, ❑ ❑ project site. D2r in.Other impacts: 17. Consistency with Community Plans The proposed action is not consistent with adopted land use plans. ®NO ❑YES (See Part 1.C.1, C.2. and C.3.) If"Yes", answer questions a-h. If"No", go to Section 18. Relevant No,or Moderate Part I small to large Question(s) impact impact may may occur occur a.The proposed action's land use components may be different from,or in sharp C2,C3,Dla ❑ ❑ contrast to,current surrounding land use pattern(s). Ela,Elb b.The proposed action will cause the permanent population of the city,town or village C2 ❑ ❑ in which the project is located to grow by more than 5%. C.The proposed action is inconsistent with local land use plans or zoning regulations. C2,C2,C3 ❑ ❑ d.The proposed action is inconsistent with any County plans,or other regional land use C2,C2 ❑ ❑ plans. e.The proposed action may cause a change in the density of development that is not C3,Dlc, ❑ ❑ Page 9 of 10 supported by existing infrastructure or is distant from existing infrastructure. Dld,Dlf, Dld,Elb f.The proposed action is located in an area characterized by low density development C4,D2c,D2d ° ❑ that will require new or expanded public infrastructure. D2j g.The proposed action may induce secondary development impacts(e.g.,residential or C2a ❑ ❑ commercial development not included in the proposed action) h.Other: ° ° 18. Consistency with Community Character The proposed project is inconsistent with the existing community character. ®NO 0 YES (See Part 1. C.2,C.3,D.2,E.3) I "Yes", answer questions a-g. I "No",proceed to Part 3. Relevant No,or Moderate Part I small to large Question(s) impact impact may may occur occur a.The proposed action may replace or eliminate existing facilities,structures,or areas E3e,E3f,E3g ❑ ❑ of historic importance to the community. b.The proposed action may create a demand for additional community services(e.g. C4 ❑ ❑ schools,police and fire) c.The proposed action may displace affordable or low-income housing in an area where C2,C3,Dlf ❑ ❑ there is a shortage of such housing. Dlg,Ela d.The proposed action may interfere with the use or enjoyment of officially recognized C2,E3 ❑ ❑ or designated public resources. e.The proposed action is inconsistent with the predominant architectural scale and C2,C3 ❑ ❑ character. f.Proposed action is inconsistent with the character of the existing natural landscape. C2,C3 ❑ ❑ Ela,Elb E2 ,E2h g.Other impacts: ° ° Page 10 of 10 Full Environmental Assessment Form Part 3-Evaluation of the Magnitude and Importance of Project Impacts and Determination of Significance Part 3 provides the reasons in support of the determination of significance. The lead agency must complete Part 3 for every question in Part 2 where the impact has been identified as potentially moderate to large or where there is a need to explain why a particular element of the proposed action will not,or may,result in a sigrificant adverse environmental impact. Based on the analysis in Part 3,the lead agency must decide whether to require an environmental impact statement to further assess the proposed action or whether available information is sufficient for the lead agency to conclude that the proposed action will not have a significant adverse environmental impact. By completing the certification on the next page,the lead agency can complete its determination of significance. Reasons Supporting This Determination: To complete this section: e Identify the impact based on the Part 2 responses and describe its magnitude. Magnitude considers factors such as severity, size or extent of an impact. • Assess the importance of the impact. Importance relates to the geographic scope,duration,probability of the impact occurring,number of people affected by the impact and any additional environmental consequences if the impact were to occur. • The assessment should take into consideration any design element or project changes. • Repeat this process for each Part 2 question where the impact has been identified as potentially moderate to large or where there is a need to explain why a particular element of the proposed action will not,or may,result in a significant adverse environmental impact. o Provide the reason(s)why the impact may,or will not,result in a significant adverse environmental impact • For Conditional Negative Declarations identify the specific condition(s)imposed that will modify the proposed action so that no significant adverse environmental impacts will result. • Attach additional sheets,as needed. Determination of Significance-Type 1 and Unlisted Actions SEQR Status: ❑ Type 1 ❑ Unlisted Identify portions of EAF completed for this Project: 0 Part 1 0 Part 2 0 Part 3 Upon review of the information recorded on this EAF,as noted,plus this additional support information and considering both the magnitude and importance of each identified potential impact,it is the conclusion of the as lead agency that: ❑ A. This project will result in no significant adverse impacts on the environment,and,therefore,an environmental impact statement need not be prepared. Accordingly,this negative declaration is issued. ❑ B. Although this project could have a significant adverse impact on the environment,that impact will be avoided or substantially mitigated because of the following conditions which will be required by the lead agency: There will,therefore,be no significant adverse impacts from the project as conditioned,and,therefore,this conditioned negative declaration is issued. A conditioned negative declaration may be used only for UNLISTED actions(see 6 NYCRR 617A). ❑ C. This Project may result in one or more significant adverse impacts on the environment,and an environmental impact statement must be prepared to further assess the impact(s)and possible mitigation and to explore alternatives to avoid or reduce those impacts. Accordingly,this positive declaration is issued. Name of Action: Name of Lead Agency: Name of Responsible Officer in Lead Agency: Title of Responsible Officer: Signature of Responsible Officer in Lead Agency: Date: Signature of Preparer(if different from Responsible Officer) Date: For Further Information: Contact Person: Address: Telephone Number: E-mail: For Type 1 Actions and Conditioned Negative Declarations,a copy of this Notice is sent to: Chief Executive Officer of the political subdivision in which the action will be principally located(e.g.,Town/City/Village of) Other involved agencies(if any) Applicant(if any) Environmental Notice Bulletin: http://www.dec.ny_eov/enb/enb.html Revised Oct 2W8 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: Hudson Headwaters Health Network Designates: Jonathan Lapper As agent regarding: Variance Site Plan Subdivision For Tax Map.No.: 309.7 Section 1 Block _5,L__Lot Deed.'Reference: 6174 Book 279 .Page 08/12(20 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: 2.1 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. 6.1 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. . a.) AGREEMENT TO PROVIDE DOCUMENTATION REQUIRED: 1, 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. acknowledge that prior to occupying the facilities proposed, I or my agents, will obtain a. certificate of occupancy as necessary. 1 also understand that I/we may quired to provide an as-built survey by a licensed land surveyor of all newly constructed facilities prior to issua a of a certificate of occupancy I have read and agree to the above. SIGNATURE OF APPLICANT: CAO DATE: z` SIGNATURE OF AGENT: DATE: 5 309.7-1-54,55,5,5,59,60,61