Application Site Plan Review Revised June 2009
General Information
Tax Parcel ID: 3o1. G - I - 30
Zoning District: C •E
Current Use: •f 6,, ( a/Oli- LL 17 Vfie,r f A r•)
Proposed Use: Apj f „}f toceived a (0vrt/ 712 re rwcp ye a���.
7S-a) r_ v f r rf��? � �s /'cff �i�WI le•r� .dp1. /
noL/ vi vo ref 7O r.os�<
t (- P/�• r 4"V u I ey c.r/..{757
Location of project: iota /lip<filo ff,4 Ifee„ Aflute are,
bc.Gk lir// 5,../4 e••q area.. wr/f— sib‘G
fro s,/1
°f �.4€ 5t'-' /v/e1 it
Applicant Name pp Address: I X68 Saw fit.
tlxrla� s (.� . €I I tytawsa NY (32.03
Home Phone Cell: sic•782 •565Y
Work Phone 31s- 'MAI•off; s,.f 2.2.5/ Fax
E-Mail: c..4-r013 - Goy
tic • r• 64 a Leer f - e•..-
Agent's Name: MF*1'/� wes Address: Haffv,(.AJ �d tagoi{
f IOM eel." r6C y•✓e
Home Phone Cell:
Sse Absea
Work Phone slg :7'y• $(7Y Fax
E-mail
Owner's Name: D,sLtd. 44" d°(b t. i3c Wee)s- Address 14.41e. d'(14.y (?d.
R4•dl. n' . fake Lv2er..e I'Y le S'
Home Phone Cell
Work Phone sit.&lc,- 0414 Fax s(6-4tt. sv2
E-mail
Town of Queensbury Planning Office- 742 Bay Road • Queensbury,NY 12804• 518-761-8220 2
Site Plan Review Revised June 2009
Site Development Data
Area/Type Existing sq.ft Proposed Total sq. ft.
Addition sq. ft.
A. Building footprint c c0Ii r&14)
ily G3 3a 211
B. Detached Garage
C. Accessory Structure(s)
D. Paved, gravel or other hard surfaced area 3 Z`fl.
0951- 3LK43
E. Porches/Decks
F. Other
G. Total Non-Permeable [Add A-F] 3i -7 o q
39 ,7a1
H. Parcel Area [43,560 sq. ft. /acre]
(,95$4/ fGAc
I. Percentage of Impermeable Area of Site [I=G/H]
t -
c.7. I C7.
f cs i c c f c„ e4v(e a-11 31: 7(4 3 2..2. i lb After
Setback Requirements
Area Required Existing Proposed
Front[1]
7s 71 ?"I
Front[2]
Shoreline
Side Yard [1]
7-o y7.(
Side Yard [2]
3�
Rear Yard [1]
of �K.s
Rear Yard [2]
Travel Corridor 7s
- y -rt.
Height[max] Ko
rr A
Permeability
30 43
No. of parking spaces
Af01</4(/(.644.
Town of Queensbury Planning Office. 742 Bay Road •Queensbury,NY 12804• 518-761-8220 3
Site Plan Review Revised June 2009
Additional Project Information
1. Will the proposal require a Septic Variance from the Town Board of Health? A/0
2. If the parcel has previous approvals, list application number(s):
3. Does this project require coverage under the NYS DEC Stormwater Pollution Prevention Program?
4. Estimated project duration: Start Date ASk e ,1 t3 End Date Y w (1"
5. Estimated total cost of project: /b$ o go Es r
6. Total area of land disturbance for project: 11
Floor Area Ratio Worksheet
FLOOR AREA RATIO (FAR) — The relationship of building size to lot size, derived by dividing the total building
floor area by the lot size in square feet, yielding a percentage.
Zoning District Symbol Floor Area Ratio [FAR]
Waterfront Residential WR 0.22
Commercial Moderate CM 0.3
Commercial Intensive CI 0.3
A. The combined area of all square footage, as measure from exterior walls of all structures on the property, including all
floors of the structures, garages, basements and attics with more than five (5) feet of ceiling height and covered
porches. Building square footage does not include: Open deck, docks and that portion of covered docks extending
over water and one storage shed of one hundred twenty (120) square feet or less. Any additional sheds will be
included. (See`FLOOR AREA RATIO").
B. Commercial or industrial: the total area in square feet as measured from the exterior of the outside walls of a building
or structure, and when applicable, the sum total of all floor areas of the principal and accessory buildings or structures
on the project site.
Parcel Area i i“31” - - _ sq. ft.
I Existing Floor Area :i4G 3 sq. ft. [see above definition]
Proposed Additional Floor Area rY 5 2 sq. ft.
IProposed Total Floor Area 3 z. 2 4 sq. ft.
Total Allowable Floor Area Z U S a .s- (Area x . 3 ) [see above table]
Town of Queensbury Planning Office- 742 Bay Road • Oueensbury, NY 12804 • 518-761-8220 4
Site Plan Review Revised June 2009
§ 179-9-080 Requirements for Site Plan Approval. The Planning Board shall not approve a Site Pan unless it
first determines that such site plan meets the following Standards. Please prepare responses to each of the following
topics.
STANDARDS
A. The proposed project furthers or is consistent with the policies of the Town's Comprehensive Plan. V
$
t
B. The proposed project complies with all other requirements of this Chapter,including the site plan review standards as set forth in Paragraph F
of this section,the dimensional,bulk,and density regulations of the zoning district in which it is proposed to be located(Article 3 and Table 1),
the applicable requirements of all other Articles that apply. yer5
C. The site plan encourages pedestrian activity internally and.if practicahle,to and from the site with pedestrian paths or sidewalks connected to
adjacent areas. yes
D. The site plan must conform to Chapter 136 Sewage and Sewage Disposal, Chapter 147 Stormwater Management Local Law, and other
applicable local laws. yc s
E. the proposed use shall be in harmony with the general purpose or intent of this Chapter,specifically taking into account the location,character
and size of the proposed use and the description and purpose of the district in which such use is proposed,the nature and intensity of the
activities to be involved in or conducted in connection with the proposed use and the nature and rate of any increase in the burden on
{ supporting public services and facilities which will follow the approval of the proposed use.
cs
F. The establishment,maintenance and operation of the proposed use will not create public hazards from traffic,traffic congestion or the parking
of vehicles and/or equipment or be otherwise detrimental to the health, safety or general welfare of persons residing or working in the
neighborhood or to the general welfare of the town. Traffic access and circulation, road intersections, road and driveway widths, and traffic
controls will be adequate. Yc,
G. Off-street parking and loading facilities will be appropriately located and arranged and sufficient to meet traffic anticipated to be generated by
the new use. The establishment of vehicle links between parking areas of adjacent properties are provided where feasible. This furthers the
Town's goal of reducing curb cuts and reducing congestion. A twenty-foot wide connection is required. If adjacent properties are either
undeveloped or previously developed without having made provision for future linkage, then a future connection must be identified and
provided for in the site plan under review for such future linkage when the time arises. The Planning Board may reouire proof that the
applicant has made contact with adjacent property owners for purposes of coordinating linkages with adjacent properties. ye S.
H. The project shall not have an undue adverse impact upon the natural,scenic,aesthetic,ecological,wildlife,historic,recreational or open space
resources of the town or the Adirondack Park or upon the adequate provision of supporting facilities and services made necessary by the
project, taking into account the commercial, industrial, residential, recreational or other benefits that might be derived from the project. In
making the determination hereunder, the Planning Board shall consider those factors pertinent to the project contained in the development
considerations set forth herein under§ 179-9-080 of this chapter,and in so doing, the Planning Board shall make/a net overall evaluation of
the project in relation to the development objectives and general guidelines set forth in§179-9-080 of this Article. No (/nefve 4d+rc.rtt
/Miz.z ,
I. The p, vision for and arrangement of pedestrian traffic access and circulation,walkway structures,control of intersections with vehicular traffic
and overall pedestrian convenience shall be safe and adequate for pedestrian movement. Pedestrian connections between adjacent sites
shall be provided to encourage pedestrian use. }/,S,
J. Stormwater drainage facilities will prevent an increase of post development drainage flows as compared to pre-development drainage flows.
Drainage of the site shall recharge ground water to the extent practical. Surface waters flowing off-site shall not degrade any streams or
adversely affect drainage on adjacent properties or public roads. Facilities shall be in conformance with the drainage, standard of Chapter
1 47 f the Town Code and the Town of Queensbury Subdivision Regulations where applicable. Ye S. r/"('•ce.4/x+ 744 c7S+-,f
K. The water supply and sewage disposal facilities will be adequate and will meet all applicable and current requirements set forth by Department
of Health regulations and Chapter 136 of the Town Code.
re S
L. The adequacy, type and arrangement of trees, shrubs and other suitable plantings, landscaping and screening shall effectively provide a
visual and/or noise buffer between the applicants and adjoining lands, including the maximum retention of existing vegetation and
maintenance,including replacement of dead or deceased plants. fec c f e )� f��� r J
M. Fire lanes,emergency zones,and fire hydrants will be adequate and meet the needs and requirements of emergency service providers. Yes.
N. The design of structures, roadways and landscaping in areas susceptible to pending, flooding and/or erosion will minimize or avoid such
impacts to the maximum extent practicable.
C. The site plan conforms to the design standards,landscaping standards and performance standards of this chapter. YGS
Town of Queensbury Planning Office. 742 Bay Road Queensbury, NY 12804• 518-761-8220 5
Site Plan Review Revised June 2009
§ 179-9-050 Application for Site Plan Review
Application for site plan approval shall be made to the Planning Board using forms supplied by the Board:Application materials and the
site plan shall include sufficient information for the Board to make its findings under§ '79-9-070 and 179-9-050 below. In determining
the content of the site plan and supporting documentation,the Planning Board may waive certain requirements if the Planning Board
deems such requirements or information unnecessary for the type of project proposed. Any such waiver shall be made in writing, and
shall contain statements of the reasons why the waived information requirements are not necessary for an informed review under the
circumstances. The Planning Board may grant such wavers on its own initiative or at the written request of an applicant. Such request
shall set forth the specific requirements that are requested to be waived and the reasons for the requested waiver. Absent any waiver
or waivers, an application for Site Plan Review shall include the following:
Shown I
REQUIREMENTS on Sheet
� I
A A vicinity map drawn at the scale that shows the relationship of the proposal to existing community fadlities which affect or serve it. 7-i
such as roads, shopping areas, schools, etc. The map shall also show all properties, identify owners, subdivisions, streets, and c
easements within 500 feet of the property. Such a sketch may be superimposed on a United States Geological Survey map of the J
area.
B ' The site plan shall be drawn at a scale of forty feet to the inch(1"=40 feet)or such other scale as the Planning Board may deem
appropriate, on standard 24" x 36" sheets, with continuation on 814" x 11" sheets as necessary for written information. The '
information listed below shall be shown on the site plan and continuation sheets.
C Name of the project,boundaries, date,north arrow,and scale of the plan. I f t
D Name and address of the owner of record,developer,and seal of the engineer,architect,or landscape architect If the applicant is -r"
not the record owner,a letter of authorization shall be required from the owner Po- f
1'-I
E The location and use of all existing and proposed structures within the property, including all dimensions of height and floor area,all
exterior entrances,and all anticipated future additions and alterations. 5 7
F The location of all present and proposed public and private ways, off-street parking areas, driveways, outdoor storage areas,
sidewalks, ramps, curbs, paths, landscaping, walls, and fences. Location, type, and screening details for all waste disposal S-
containers shall also be shown.
G The location, height, intensity,and bulb type(sodium,incandescent,etc.)of all external lighting fixtures. The direction of illumination
and methods to eliminate glare onto adjoining properties must also be shown in compliance with§179-6-020.
H The location,height,size,materials,and design of all proposed signs.
I ( The location of all present and proposed utility systems including:
1. Sewage or septic system;
2. Water supply system;
3. Telephone,cable,and electrical systems; and
4. Storm drainage system including existing and proposed drain lines, culverts,catch basins, headwalls,endwalls, hydrants,
manholes,and drainage swales.
d Plans to prevent the pollution of surface or groundwater, erosion of soil both during and after construction, excessive runoff, and 3-
flooding of other properties, as applicable. A Stormwater Pollution Prevention Plan (SWPPP) for all land development activities
(excluding agricultural activities) on the site that results in land disturbance of 1-acre or more. A SVVPPP shall comply with the
requirements of the DEC SPDES MS-4 General Permit and Chapter 147 of the Town of Queensbury Code. It shall be at the
discretion of the Planning Board as to whether a SWPPP or an erosion and control plan shall be required for a site plan review project
land disturbance of less than 1-acre.
K Existing and proposed topography at two-foot contour intervals, or such other contour interval as the Planning Board shall allow. All S
elevations shall refer to the nearest United States Coastal and Geodetic Bench Mark. If any portion of the parcel is within the 100-
year floodplain,the.area will be shown, and base flood elevations given. Areas shall be indicated within the proposed site and within
50 feet of the proposed site where soil removal or filling is required,showing the approximate volume in cubic yards.
L
A landscape plan showinc all existing natural land features that may influence the design of the proposed use such as rock outcrops, S ,
stands of trees, single trees eight or more inches in diameter, forest cover, and water sources, and all proposed changes to these
features including sizes and types of plants. Water sources include ponds, lakes, wetlands and watercourses, aquifers,floodplains,
and drainage retention areas. d<t S
M l Land Use District boundaries within 500 feet of the site's perimeter shall be drawn and identified on the site plan, as well as any CC
Overlay Districts that apply to the property. J i
Town of Queensbury Planning Office- 742 Bay Road- Queensbury, NY 12804• 518-761-8220 6
Site Plan Review Revised June 2009
N Traffic flow patterns within the site,entrances and exits, and loading and unloading areas,as well as curb cuts on the site and within
100 feet of the site. The Planning Board may,at its discretion,require a detailed traffic study for large developments or for those in s. j
heavy traffic areeas,which shall include:
1. The projected number of motor vehicle trips to enter or leave the site, estimated for weekly and annual peak hour traffic Pi'
levels;
2. The projected traffic flaw pattern including vehicular movements at all major intersections likely to be affected by the
proposed use of the site;
3. The impact of this traffic on levels of service on abutting public streets and at affected intersections. Existing and proposed
weekly and annual peak hour traffic levels and road capacity levels shall also be given.
0 For new construction or alterations to any structure,a table containing the following information shall be included: ;
1. Estimated area of structure to be used for particular purposes such as retail operation,office,storage.etc.; Ye
2. Estimated maximum number of employees;
3. Maximum seating capacity,where applicable;and
4. Number of parking spaces existing and required for the intended use. !7
P 1. Floor Plans. 6
2. Elevations at a scale of one-quarter inch equals one foot(1/4"=1 foot)for all exterior facades of the proposed structure(s)and/or A.)
alterations to or expansions of existing facades,showing design features and indicating the type and color of materials to be used.
A-y
Q Soil logs, water supply well and percolation test results, and storm runoff calculations, as needed to determine and mitigate project tie)
impacts.
R Plans for disposal of construction and demolition waste,either on-site or at an approved disposal facility. 14d 0 MLr-
1 S Plans for snow removal,including location(s)of on-site snow storage.
T An Environmental Assessment Form("EAF"),as required by the SEQP,A regulations,with Part I completed by the Applicant shall be
submitted as part of the application. If the proposed project requires a special use permit and an EAF has been submitted in
conjunction with a special use permit application,a duplicate EAF is not required for the site plan application..
U If an application is for a parcel or parcels on which more than one use is proposed,the applicant may submit a single application for
all such uses provided the proposed uses are accurately delineated on a site plan drawn pursuant to the requirements set forth
above. The Planning Board may grant the application with respect to some proposed uses and not others. For purposes of
reviewing an application (and for SEQRA compliance) all proposed uses on a single parcel or on contiguous parcels shall be
considered together.
V A brief narrative statement on how the project proposed for review furthers or is consistent with the vision,goals and policies in the `"" �M
Town's Comprehensive Plan. Per 4 S<e•,G
Town of Queensbury Planning Office. 742 Bay Road • Queensbury, NY 12804• 518-761-8220 7
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•
Site Plan Review Revised June 2009
Pre-Submission Conference Form 1179-4-0401 r
1. Tax Map ID .`p — +' 3 0
2. Zoning Classification C cArrt erc I;�.` Lt_Alen.S( - '-
3. Code Reference for Review ,ina S 100 Con Cz
4. Ordinance Reference#: 1 - -CC/ ' G Z one__ !Ye-c,V' -0�
re,.);e pp ay.-
5. Pre-Submission Meeting Notes;Outstanding Items To Be Addressed Include:
Deed V Yes No •
General Information complete Yes No E ipC.2c. PrEP ev'S"ted
Site Development Data Complete Yes No
Setback Requirements Complete -7 Yes No
Additional Project Information Complete ' Yes No
*Coverage under DEC SWPPP Program 4...-7T Yes No
FAR Worksheet complete ✓Yes No
Standards addressed ✓Yes No
Checklist items addressed Yes No 1 i?P d S"I
Environmental Form completed TXes No A)Pr C sc,.. "-
Signature Page completed ✓Yes No
CL.S• cJ pi tCc /t t2.�-{.1i 4-1kt Zet,O ( Z' 4400 0(k 0 zit
A nc,1crcrt - c ir,C Ce& Kock c(xchv/1 c P ci3 0/3 - K. (7<erczd�v
rift 4 L(rrVta red( toC i
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'Applicant must provide office with Notice of Intent(NOI):SWPPP Acceptance Form,DEC letter issuing permit number:
Notice of Termination(NOT)
q/ 7/Staff Representative: !-EAU )t Ck it�'LG "i/�
1'Z-711--7/1
Applicant/Agent:
Date:
Town of Queensbury Planning Office.742 Bay Road•Queensbury,NY 12804.518-761-8220 8
Site Plan Review Revised June 2009
-.41E-4 11t!95,—Text 12
• PROJECT I.C.NUM3ER 617.20
1 SEOR
Appendix C
State Environmental Quality Review
SHORT ENVIRONMENTAL ASSESSMENT FORM
For UNLISTED ACTIONS Only
PART I—PROJECT INFORMATION To be completed by Applicant or Protect sponsor)
APPLICANT,'SPONSOR
A-A-r fL j t-1- 2. PROJECT NAME
6Ua`G sry fzt niCF
PROJECT LOCATION:
Municipality Qvs C e 3 4 f
County roil r/en
A. PRECISE LOCATION(Street address anC rtad Intersections,prominent landmarks,etc.,or provioe mapl
Gro /a, f9,- Rd
5. IS PROPOSED ACTION:
❑New ❑Expanolpn ZodiflcatiorJalleralion
E. DESCRIBE PROJECT BRIEFLY; ( /
ti'n 4rG4 4,./t /..rscl• Apo Jr44-k et
7. AMOUNT OF LAID LFFECTSD:
Initially l acres uttlfi ateIy
acres
E. WILI:IROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LANG USE RESTRICTIONS?
Yes ❑NO ff No, describe briefly
9. WHAT IS PRESENT LAND USE IN VICINITY�OFr,AROJECT?
0 Residential ❑Industrial L�Commercial ❑Agriculture 0 ParIUForestrOpen space
0
Desioe: �t Other
10. DOES ACTION INVOLVE A PERMIT APPROVAL OR FUNDING,NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY(FEDc'2r AL
STATE OR LOCALI? -
GOVE
Q'4ea 0No If yes,list agency(s)aria parmWaoprovals
(3„r(,1. - jrr"^rf
. DOES ANY ASPECT i� OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL?
C es ❑NO If yes,list agency name and permit/approval
•2. A�SA RESULT OF PROPOSED ACTION WILL EXISTING PERMITIAFPROVAL REQUIRE MODIFICATION?
acres ONO
i CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF 1/,Y KNOWLEDGE
APPlidanVspdnsor Hama' C6//.l f &. (7,—, Qr e7c.- -�!!w ` ,� • 1 J ` /2
G it J l .Date: f
I Sgnatur<: 7 W/f..---- (a.c(q T )
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
Town of Queensbury Planning Office. 742 Bay Road• Queensbury, NY 12804• 518-761-8220 9
•
Site Plan Review Revised June 2009
• PART I1—ENVIRONMENTAL ASSESSMENT(To be completed by Agency)
A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR PART 617.4? If yes,coomlrale the review Process and use ma FULL EAF.
❑Yes CI No
B. WSLL ACTION RECEIVE COORDINATED REVIEW AS.PROVIDED FOR IINUSTED ACTIONS IN 6 NYCRR,PART 617.6? If No.a negative declaration
may be superseded by another inyaved agency.
❑Yes No
C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING:(Answers may be handwritten,if legible)
C1. Existing air quality, surface or groundwater quality at%Mety,h0(ae levels, existing traffic patterns,solid waste production or disposal,
potential for erosion,drainage or flooding problems?Explain briefly:
C2. Aesthetic agricultural,archaeological,historic,or other natural or cultural resources;or community or neighborhood character?Explain briefly
03. Vegetation or fauna,flat,shellfish or wildlife species,significant habitats,or threatened or endangered species?Explain briefly:
C4. A community's existing plans or goals as officially adopted,or a cnange in use or intensity of use 01 land or other natural resources?Explain briefly
C5. Growth,subsequent development,or related activities likely to.be induced Dy the proposed action?Explain briefly.
CS. Long term,short term,cumulative,or other affects not Identified In Ct.C5?Explain briefly.
C7. Other impacts(Including changes in use of either quantity or type of energy)?Explain briefly.
D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTASUSHM ENT OF A CEA?
Yee El No
E. 1S THERE,OR IS THERE LIKELY TO BE,CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS?
Cr Yes ❑No 11 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 0 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
documentation, that the proposed action WILL NOT result In any significant adverse environmental impacts
AND provide on attachments as necessary, the reasons supporting this determination:
Name of Lead Agency
?tint or Type Name of Responsible Officer rn Lead Agency
Tnie of ReEponsLek Officer
Signature of Responsible Officer on Lead Aaenty
Signature 01 Freparer Inc drrlerent rrom res
•
PonsiO:e officer
Date
2
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Town of Queensbury Planning Office. 742 Bay Road• Queensbury,NY 12804. 518-761-8220 10
01/12/2013 15:03 FAL1 315 475 P816 CARROLS CORP Oil
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Site Plan Review Revised June 2008
Signatur: Page
This page includes the 1.) Aut`u r;zation to Act as Agent Forr is 2.) Engineering Fee Disclosure: 3.E Authorization for Site
Visits; 4.) Other Permit Respor s!bilftles;: 5.) Official .Meetinc Disclosure and 6.) Agreement to provide documentation
required.
OWNER'S AGENT FORM:
Complete the following if the CV NER of the property Is not thi same as the applicant
Owner; "wb)e iii • . f C2.4 .•4 •
Designates:
C.lrrl • t-✓.. or ,t'r
As agent regarc ng: /K Variance k. Site Plan k Subdivision
For Tax Map Nt.; 302.0 Secticn t Block 3 Ga_Lot
Deed Rererenc ; Book __Page Dale
OWNER SIGNATURE: DATE:
APPL1cAt T's AGENT FORM: .
Complete the foil-Owing if the AF PLICANT is unable to epend the meeting or wishes to be represented by ano her party:
Owner: Do.G( � !d:(R t.{ L w.,a; /C,rr.lf ire
Designates: 12;,. 74 7C".r�,f• ,Qip.f /nnrrfflve f
As agent regarc ing: k Variance, _site Plan Lr Subdivision .
For Tax Map NI ,: 1.2.c Section ••_j_Block Lot
Deed Referent t: • Book _Page Date
OWNER SIGNATURE;- DATE: .
•
�} EhltilitgEERWG FEE DISCLQ>URE: Applications may be ref tried to the Town consulting engineer for review of septic design,
storm dralnags, etc. as determine ti by the Zoning or Planning Di-partrnent, Foes for engineering review services will be charged
directly to the applicant: Fees for e igineering review will not exceec $1,000 without notification to tno applicant.
3.) AUTHORIZATION FOF $1T1t /1SITS: By signing this page al d submitting the application materials attached herein,the Owner,
Applicant, and his/her/their agent sl hereby author the Zanlnf Board or Planning Board and Town 3tatf to enter the subject
properties for Ina f tspose of reviev ing the application submitted:
4.) OTHER PERMIT RESPONSIB L1TiES: Other permits may be r:quired for constnxdon air alteration activity subsequent to approval
by the Zoning Board or Planning Br•ard. It is the applicant's resp3ri biTity to obtain any additional permits.
5.) OFFICIAL werriNG MlM1iTE r DI$CLOSURE: 1r is the practir a of the Community Development Department to have a designated
otenog•apher ape record the proo:edtngs of meetings resulting troll application.and minutes transaibedfrort thosetaoes constitutes
the official record of all proceeding:.
6,),_PGREEMENT TO PROVIDE DOCUMENTATIOJ REQUIREII: I, the undersigned, have thoroughly read and understand the
instuotions for submission and a4'se to the submission requiremi nts, i acknowlecge no censtrucuon activities shell be commenced
prior to issuance of a valid pei Mit. I certify that the septic;tiori, pans and supporting materials are x true and complete
sltementideeorpticn of the exist!ig oanditions and the work prof osed, and that all work wit be periirmed In accordance with the
approved plans and in confcrrnanc a oral local zoning regulations. acknowledge that prior to occupying the facilities proposed, !or my
agents.will obtain a certificate cia roupanoy as neceseery. I also u iderstand that i1we may be required to provide an as built survey by
a licensed land surveyor of all new 'constructed facilities prior to a:uarce of a certificate of occupancy
I have read and agree to the a!-we.
,vr /' F east I/�"e /l (. 3
Si! l p.lbcan. - Print Name [Applt ant] .Dat7 tiy7d
• C Yvk Ac. ∎04.11.8 r'O fi
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Ignst a ••=nt] Print Name[Agerr - Date signed
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Town of Queens oury Planning Office- 742 Bay R,red Queensbury,NY 12804.510-761-8220