Application - Revisedw
Application No. (Office Use Only)
Project Location:
Tax Map ID:
Zone Classification:
Detailed Description of Project:
(include current & proposed us
Applicant:
Address:
Home Phone:
Work Phone / Fax:
Applicant's Agent:
Address:
Home Phone:
Work Phone / Fax:
General Information
OC 12,
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Property Owner: F/MLXr ZT ,S (At 1 5kl -� i
Address: fo`2d Q�►hGC�
62-
Home Phone:
Work Phone / Fax: -19 2 -
-)I
Directions to Site:
Site Development Data
Area / Type
Existing sq. ft.
Proposed Addition
ft.
Total sq. ft.
A Building Footprint
B. Detached Garage
C. Accessory Structure(s)
D. Paved, gravel or other`
hard surfaced areas
�o
E. Porches / Decks
F. Other
Total Non -Permeable
Sum A through F)
000
Parcel Area
Percent Non -Permeable
Dial Non-Pemmeablditcd Ara)
p p�
Setback Requirements
Required
Existing
Proposed
Front 1
�p
From 2
Shoreline
Side Yard 1
0
Side Yard 2
Rear Yard 1
Rear Yard 2
Buffer / Travel Corridor
S0
Height
Permeability
t
14-164 (11/95)—Text 12
PROJECT 2.0. NUMBER 617.20 SEQR
Appendix C
State Environmental Quality Review
SHORT ENVIRONMENTAL ASSESSMENT FORM
For UNLISTED ACTIONS Only
PART I —PROJECT INFORMATION (To be completed by Applicant or Project sponsor)
1.
APPLICANT /SPONSOR
La k-P i� 7rk wk.S &fwws
2. PROJECT NAME
3.
PROJECT LOCATION:
Municipality County
A.
PRECISE LOCATION (Street address and road intersections, prominent landmarks, etc., or provide map)
5.
IS PIR-OSED ACTION:
tuNew ❑Expansion ❑ ModifieatloNalteration
6.
DESCRIBE PROJECT BRIEFLY:
D t5 9"� ev- 9-4N
7.
AMOUNT OF LAND AFFECTED:
Initial) Y acres Ultimate) acres
S.
WILLPROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS?
YJ Yes : ❑ No If No, describe briefly
9.
WHAT IS PRESENT LAND USE IN VICINITY OF $ROJECT?
❑ Residential ❑ Industrial rL-Sr/Commercial ❑ Agriculture ❑ ParlJForest/Open space ❑ Othw
Describe:
10.
DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL,
STATE 04T LOCAUr
Yes No N yes, list agency(s) and permiVapprovals
.
11.
_ 90F$ ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL?
7v19pt,
Tomes If yes. list agency name and permit/approval
v
/to�lrNro
(t-ri./�L'•��Y�J r `-t C.\'EGI \.X�.r
J
12.
AS A RESULT OF P/gpPpSED ACTION WILL EXISTING PERMTnAPPROVAL REQUIRE MODIFICATION?
❑ Yes Idtip
I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUETOTHE BEST OF MY KNOWLEDGE
ADpliant/sponsor
1
n --rl L Date
Signature
If the action is In the Coastal Area, and you are a state agency, complete the
Coastal Assessment Form before proceeding with this assessment
OVER
PART II —ENVIRONMENTAL AESSMENT (To be completed by Agencs
A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR PART 617.4? If yes, coordinate the review process and use the FULL FAF.
❑Yes o
B. WILL ACTION R CEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? If No. a negative declaration
may be superseded by another involved agency.
❑ Yes %No
C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may oe handwritten, if legible)
C7. Existing air quality. surface or groundwater quality or quantity, noise levels, existing traffic patterns, solid waste production or disposal,
potential for erosion, drainage or flooding problems? Explain briefly:
�b
C2 Aesthetic agricultural. archaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly:
Nb
C3. Vegetation or Ifauna, fish, shellfish of wildlife species, significant habitats, or threatened or endangered species? Explain briefly:
a�
ITU
C<. A communitys existing plans or goals as officially adopted, or a change in use or intensity of use of land or other natural resources? Explain briefly
q0
05. Growth, subsequent development, or related activities likely to be induced by the proposed action? Explain briefly.
�D
C6. Long term, short term, cumulative, or other effects not identified in C1f357 Explain briefly.
N 0
C7. Other impacts (imfuding changes in use of either quantity or type of energy)? Explain briefly.
f�0
D. WILL THE PR OJE HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CEA?
❑Yes o
E. IS THERE, OR IS THERE LIKELY To BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS?
❑ Yes �.po If Yes, explain briefly
PART III —DETERMINATION OF SIGNIFICANCE (To be completed by Agency)
INSTRUCTIONS: For each adverse effect identified above, determine whether It Is substantial, large, important or otherwise significant.
Each effect should be assessed in connection with Its (a) setting (i.e. urban or rural); (b) probability of occurring; (c) duration; (d)
irreversibility, (e) geographic scope; and (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure that
explanations contain sufficient detail to show that all relevant adverse impacts have been identified and adequately addressed. If
question D of Part II was checked yes, the determination and significance must evaluate the potential Impact of the proposed action
on the environmental characteristics of the CEA
❑ Check this box if you have identified one or more potentially large or significant adverse impacts which MAY
occur. Then proceed directly to the FULL EAF and/or prepare a positive declaration.
Check this box if you have determined, based on the information and analysis above and any supporting
documental' nit the proposed action WILL NOT result in any significant adverse environmental impacts
AND pr eon achments as necessary, the reasons supporting this determination:
Name tie Lea Agency
_ A,.� I 17 l _ PLO ldj�
:er in Lead Agency SitinaturV
mparer
g 'al o
Dare
Checklist - Please prepare a map depicting existing and proposed conditions. Failure to complete
the following checklist or include all the required information on your plot plan will result in a
determination of incompleteness and a delay in the processing of your application.
*Check IInitial Each Box
P—Provided
NA —Not Applicable
WR — Waiver Re4 Fuested
ADDRESS EACH ITEM
P
NA
WR
GENERAL
A Title, name, address of applicant & person responsible for preparation of drawing
B. North arrow, Tax Map ID, date prepared and scale (minimum I in. = 40 fl.)
C. Boundaries of the property plotted to scale, zoning boundary
D. Location of principal structure, accessory structures with exterior dimensions
E. Location of site improvement; including outdoor storage areas, driveways (existing
and areas, etc.
F. Setbacks for all strictures and improvements
WATER & SEWER
A. Location of on -site sewage disposal facilities, design details, construction details.
flow rates, and number of bedrooms served
/
✓
B. Location of water supply (i.e. well) and septic on adjoining lots with separation
distances to exming or proposed on -site water supply and septic.
C. Separation distances for proposed sewage disposal system to well and waterbodies.
D. Location and description of existing public or private water supply (well, lake, etc.).
Method of securing public or private water, location, design and coasft=on of
water suridy including dinly water usage
E. Percolation test location and results.
PARK NG / PERMEABLE AREAS
A No. of spaces required for project including calculations and justification.
/
✓surflicing
B. No. of existing parldng spaces, no. to be removed, no. to maintain and type of
material (e.paced).
✓
C. Provision for pedestrian and handicap access and parking
D. Location ad design details of ingress, egress, loading areas and cutting
E. Location and character of green areas (existing and proposed), modification to green
buffer zone to remain undisturbed
F. Lighting location and design of all existing or proposed outdoor lighting
ADDITIONAL SITE DEVELOPMENT AND MISCELLANEOUS
A Location of on -site & adjacent watercourses: streams, rivers, lake and wetlands.
B. Location of proposed & existing: utility/energy distribution systems (gas, electric,
solar, telephone.
/
C. Location, design, and construction of all existing and proposed site improvements
including: drams, culverts, retaining walls, fences, fire & emergency zones and
/
d
D. Location and amount / portion of building area proposed for office, manufacturing,
retail sales. or ether commercial activities.
E. Sigoage: Location, size, type, design and setback
Signature Page
This Page includes the Authorization to Act as Agent Form, Engineering Fee Disclosure, Other Permit.
Responsibilities and Agreement to provide documentation required.
Complete the following ifthe OWNER ofthe property is not the same as the applicant
Owner's Agent Form pp
Owner: Pile 1 'Si, rdwcCa Tt
Designates: Po r15 c p
As agent regarding _✓ Variance �-,- Site Plan _ Subdivision
For Tax Map No.: i ii o Section 1 Block t•2l Lot
Deed Reference: Book _Page _ Date
SIGNATURE: (Owner) / Q 3 g(�te)
Complete the following if the LIC is unable to attend the meeting or wishes to be represented by
another party:
Owner: Cz(tr� 7.«.6
Designates: c WA
As agent regarding: _ V c�Sit Ian _ Subdivision
For Tax Map No.: Section Block
SI ATURE: (Owner) (Date)
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 SI,000 without notification to the applicant.
Please Note: 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.
Official Meetine Minutes Disclosure: it is the practice of the Community Development Dept to have a
designated stenographer tape record the proceedings of meetings resulting from application, and that minutes
transcribed from those tapes constitute the official record of all proceedings. If there is a discrepancy
between such record and the handwritten minutes taken by the designated stenographer, the handwritten
minutes shall be deemed the official record.
I, the undersigned, have thoroughly read and understand the instructions for submission, agree to the
submission requirements and completed the checklist,
SIGNATURE OF APPLICANT:
SIGNATURE OF AGENT: Date