HomeMy WebLinkAbout20230087 85 Nelson Use Variance ApplicationCARUSONE & CARUSONE
Attorneys at Law
491 Broadway — P.O. Box 478
Saratoga Springs, New York 12866
Tel. (518) 584-3240
Fax (518) 584-7451
i caru sone(a)carusonelaw.com
February 16, 2023
Via Email and Hand Delivery
Zoning Board of Appeals
City of Saratoga Springs
474 Broadway
Saratoga Springs, NY 12866
Re: Ted Waite / Application for Use Variance at 85 Nelson Avenue
Dear Members of the Zoning Board:
I am enclosing herewith the Application of Theodore Waite for a Use Variance to use the above
premises as a two-family residence. Also enclosed please find a Short Environmental
Assessment Form in this matter. Since this Application is, in most respects, similar to the
previous Application for use as a three-family residence, I would kindly request that all of the
material which we presented in connection with the three-family Application be incorporated by
reference in this instant Application. If there are any changes to the material necessitated by the
fact that this is now a two-family Application, it will be slight and I will bring such changes to
the attention of the Board.
I am also enclosing herewith our check in the sum of $1,450.00 as payment of the required filing
fee.
Thank you,
JCC/dfm
Enclosures
cc: Theodore Waite, via email only
Jacqueline White, Esq., via email only
[FOR OFFICE USEI
CITY OF SARATOGA SPRINGS
A w
C 9 Ha L - 474 6roaAwu.9
%..t S"a"o-Spri4%gk, N&w-York 12866
` Tel:. 518-587-3550 � 518-580-9480
APPLICATION FOR:
Name
Address
Phone _
Email
(Application #)
(Date received)
APPEAL TO THE ZONING BOARD FOR AN
INTERPRETATION, USE VARIANCE, AREA VARIANCE AND/OR VARIANCE EXTENSION
APPLICANT(S)*
Theodore J. Waite, III
85 Nelson Avenue
Saratoga Springs, NY 12866
518-441-6939
theowaite@aol.com
OWNER(S) (If not applicant)
ATTORNEY/AGENT
John J. Carusone, J
491 Broadway
Saratoga Springs, NY 12866
/ 518-584-3240 /
jcarusone@carusonelaw.com
* An applicant must be the property owner, lessee, or one with an option to lease or purchase the property in question.
Applicants interest in the premises: 0 Owner ❑ Lessee
PROPERTY INFORMATION
85 Nelson Avenue
I. Property Address/Location:
05/13/2013
❑ Under option to lease or purchase
179 21 2 19
Parcel No.: _
(tor example: 165.52 — 4 — 37)
UR2
2. Date acquired by current owner: 3. Zoning District when purchased:
3 Family Residential UR2
4. Present use of property:
S. Current Zoning District:
6. Has a previous ZBA application/appeal been filed for this property?
❑ Yes (when? For what?
❑ No
7. Is property located within (check all that apply)?: ❑ Historic District ❑ Architectural Review District
❑ 500' of a State Park, city boundary, or county/state highway?
8. Brief description of proposed action:
Variance to permit premises to be used as a 2 family residence.
9. Is there a written violation for this parcel that is not the subject of this application? 0 Yes ❑ No
10. Has the work, use or occupancy to which this appeal relates already begun? Yes No
11. Identify the type of appeal you are requesting (check all thatapply).
❑ INTERPRETATION (p. 2) ❑ VARIANCE EXTENSION (p. 2) 0 USE VARIANCE (pp. 3-6) ❑ AREA VARIANCE (pp. 6-7)
Revised 0112019
ZONING BOARD OFAPPEALSAPPL/CAT/ON FORM PAGE 2
FEES: Make checks payable to the "Commissioner of Finance". Fees are cumulative and required for each request below.
❑ Interpretation $ 500
❑ Use variance $1,000
❑ Area variance
-Residential use/property: $ 200
-Non-residential use/property: $ 600
❑ Extensions: $ 150
—PLEASE ANSWER THE FOLLOWING (add additional information as necessary):
Identify the section(s) of the Zoning Ordinance for which you are seeking an interpretation:
Section(s)
2. How do you request that this section be interpreted?
3. If interpretation is denied, do you wish to request alternative zoning relief? dyes ❑No
4. If the answer to #3 is "yes," what alternative relief do you request?❑ Use Variance ❑ Area Variance
EXTENSION OF A VARIANCE— PLEASE ANSWER THE FOLLOWING (add additional information as necessary):
I . Date original variance was granted: 2. Type of variance granted? ❑ Use ❑ Area
3. Date original variance expired:
5. Explain why the extension is necessary. Why wasn't the original timeframe sufficient?
When requesting an extension of time for an existing variance, the applicant must prove that the circumstances upon which the original
variance was granted have not changed. Specifically demonstrate that there have been no significant changes on the site, in the
neighborhood, or within the circumstances upon which the original variance was granted:
Revised 01/2019
ZON/NGBOARD oFAPPEALsAPPUCA T/ON FORM
PAGE 3
USE VARIANCE — PLEASE ANSWER THE FOLLOWING (add additional information as necessary):
A use variance is requested to permit the following:
For the Zoning Board to grant a request for a use variance, an applicant must prove that the zoning regulations create an unnecessary
hardship in relation to that property. In seeking a use variance, New York State law requires an applicant to prove all four of the following
"tests".
That the applicant cannot realize a reasonable financial return on initial investment for any currently permitted use on the property.
"Dollars & cents" proof must be submitted as evidence. The property in question cannot yield a reasonable return for the following
reasons:
Applicant purchased the premises believing it to be a three family residence. Attached are the following: Property record
dated 02/05/2013, School tax bill for tax year 2012/13; City tax bill for 2013; School tax bill for tax year 2019/20: and City tax
bill for 2020, all of which show the premises to be a three family on the City tax roll both before and after applicant
purchased the premises. Applicant relies on the income from the subject premises for his retirement income.
A. Submit the following financial evidence relating to this property (attach additional evidence as needed):
5/13/2013 801,500.00
1) Date of purchase:
Purchase amount:
2) Indicate dates and costs of any improvements made to property after purchase:
Date Improvement
2019 New roof
2013
2013
3) Annual maintenance expenses:
Interior painting
Upgraded appliances
3,000.00
4) Annual taxes:
Cost
$27,000
$15,000
$10,000.
11,989.46
75,000.00
5) Annual income generated from property: $
413,000.00 .62 666.129.0
6) City assessed value: $ Equalization rate: Estimated Market Value: $ 0
n/a
7) Appraised Value: $ Appraiser: Date:
Appraisal
Revised 01/2019
ZONING BOARD OfAPPEA[SAPPucAT/ONfORM
PAGE 4
B. Has property been listed for sale with (DYes If "yes", for how long?
the Multiple Listing Service (MLS)? IoNo
1) Original listing date(s): Original listing price:
If listing price was reduced, describe when and to what extent:
2) Has the property been advertised in the newspapers or other publications? ❑Yes ONo
If yes, describe frequency and name of publications:
3) Has the property had a "For Sale" sign posted on it? ❑Yes 0 No
If yes, list dates when sign was posted:
4) How many times has the property been shown and with what results?
N/A
2. That the financial hardship relating to this property is unique and does not apply to a substantial portion of the neighborhood.
Difficulties shared with numerous other properties in the same neighborhood or district would not satisfy this requirement. This
previously identified financial hardship is unique for the following reasons:
To the knowledge of the applicant, the subject property is the only one in the neighborhood which has been assessed as a three
family residence without either a zoning variance or the property being grandfathered.
Revised 01/2019
ZONINGBOARD oPAPPE4LSAPPL1C4T/ONF6RN
PAGE 5
3. That the variance, if granted, will not alter the essential character of the neighborhood. Changes that will alter the character of a
neighborhood or district would be at odds with the purpose of the Zoning Ordinance. The requested variance will not alter the
character of the neighborhood for the following reasons:
Between Wright Street and Crescent on the westerly side of Nelson are the following properties and uses:
1. Corner of Nelson and Wright -Commercial Parking lot
2. 93 Nelson Avenue -Single Family
3. 89 Nelson Avenue -Single Family with detached carriage house
4. 87 Nelson Avenue -Single Family with detached garage / apartment
5. 85 Nelson Avenue (subject property) - 3 Family
6. 83 Nelson Avenue -Two Family
7. 81 Nelson Avenue -Single Family with large commercial parking lot
8. 75 Nelson Avenue -Race View (believed to be multi -units)
See attached continuation.
4. That the alleged hardship has not been self-created. An applicant (whether the property owner or one acting on behalf of the property
owner) cannot claim "unnecessary hardship" if that hardship was created by the applicant, or if the applicant acquired the property
knowing (or was in a position to know) the conditions for which the applicant is seeking relief. The hardship has not been self-created
for the following reasons:
As previously noted, the subject property has been listed on the tax rolls of the City of Saratoga Springs as three family since prior
to the acquisition of the subject property by the applicant. The applicant had a right to rely on the designation of the property by
the City of Saratoga Springs and the hardship is therefore not self-created.
Revised O1/2019
ZONINGBOARD oFAPPEALSAPPL/CAT/ONPORM
PAGE 6
AREA VARIANCE — PLEASE ANSWER THE FOLLOWING (add additional information as necessary):
The applicant requests relief from the following Zoning Ordinance article(s)
Dimensional Requirements
Other:
From To
To grant an area variance, the ZBA must balance the benefits to the applicant and the health, safety, and welfare of the neighborhood and
community, taking into consideration the following:
1. Whether the benefit sought by the applicant can be achieved by other feasible means. Identify what alternatives to the variance have
been explored (alternative designs, attempts to purchase land, etc.) and why they are not feasible.
2. Whether granting the variance will produce an undesirable change in the character of the neighborhood or a detriment to nearby
properties. Granting the variance will not create a detriment to nearby properties or an undesirable change in the neighborhood
character for the following reasons:
Revised 01/2019
ZONING BOARD OFAPPF4LsAPPLLC4T1oNF0RM PAGE
3. Whether the variance is substantial. The requested variance is not substantial for the following reasons:
4. Whether the variance will have adverse physical or environmental effects on neighborhood or district. The requested variance will not
have an adverse physical or environmental effect on the neighborhood or district for the following reasons:
5. Whether the alleged difficulty was self-created (although this does not necessarily preclude the granting of an area variance). Explain
whether the alleged difficulty was or was not self-created:
Revised 0112019
ZONING BOARD OF APPEAa APPL /c4 r/ON FORN
PAGE 8
DISCLOSURE
Does any City officer, employee, or family member thereof have a financial interest (as defined by General Municipal Law Section 809) in
this application? 0 No ❑ Yes If "yes", a statement disclosing the name, residence and nature and extent of this interest must be filed
with this application.
APPLICANT CERTIFICATION
I/we, the property owner(s), or purchaser(s)/lessee(s) under contract, of the land in question, hereby request an appearance before
the Zoning Board of Appeals.
By the signature(s) attached hereto, I/we certify that the information provided within this application and accompanying
documentation is, to the best of my/our knowledge, true and accurate. I/we further understand that intentionally providing false or
misleading information is grounds for immediate denial of this application.
Furthermore, I/we y au orize the members of the Zoning Board of Appeals and designated City staff to enter the property
associated wit is appli ion for purposes of con any necessary site inspections relating to this appeal.
Date:
7 (applic t s' nat
Date:
(applicant signature)
If applicant is not the currently the owner of the property, the current owner must also sign.
Owner Signature:
Owner Signature:
Date:
Date:
Revised 01/2019
Continuation of Paragraph 3
On the west side of Nelson Avenue, south of Crescent Street there is the
Horseshoe Bar and Restaurant, Brentwood Motel, and Mexican Connection, all of which
operate year round. On the east side of Nelson Avenue, across from the subject premises
is the Saratoga Race Track.
The use of the applicant's property as a three family residence will in no way alter
the character of the neighborhood.
J
5
For Fiscal Year 01/01/2020 to 12/31/2020 2020 CITY & COUNTY TAX BILL
*warrant Date 12/31/2019 CITY OF SARATOGA SPRINGS
Bill NO.: 005533
MAKE CHECKS PAYABLE TO
COMMISSIONER OF FINANCE
PO BOX 328
SARATOGA SPRINGS NY
12866-0328
179.21-2-19
Waite Theodore J III
Waite Barbara J
2 Stable Ln
Saratoga Springs, NY 12866
TO PAY IN PERSON
SARATOGA SPRINGS REC
M SAM - 5PM T-P 9AM -
WWW,SARATOGA-SPRINGS.
ANY ADIRONDACK TRUST
518-587-3550
PROPERTY ADDRESS & LEGAL DESCRIPTION
SWIS: 411501 SB/L 179.21-2-19
CENTER 4:30PM Address: 85 Nelson Ave
ORG City of: Saratoga Springs
CO SCbPj .—Sarat0SW1 ngs Csd
12ott Sect
Acreage: .35
Estimated State Aid: Cory: 35, 795, 935
City: 1,649,701
PROPERTY TAXPAYER'§ BILL OF RIGHTS
The assessor estimates the Full Market Value of this property as of JULY 1, 2018 was: 656,556
The Total Assessed Value of this property is: 413,000
The Uniform Percentage of Value used to establish assessments in your municipality was: 63.00%
If you feel your assessment is too high, you have the right to seek a reduction in the future. A publication entitled "Contesting
your assessment" is available at the assessor's office and online at www.tax.uy.eov Please note that the period for filing
complaints on the above assessment has passed. Apply for Third Party Notification By: 11/ot/2020
xfSrPTION VALUE T. K NPOSE FULL VALUES . PITON EREARRON V'U'm T.VL PURPOSE FULL VALUE EIOMPRON
rROPERTY TAXES
'axing Purpose
Total Tax Levy
%Levy Change
From Prior Year
Taxable Assessed Value
Rates per $1o00
IENERAL COUNTY
or Units
or per Unit
Tax Amount
IYS MANDATES
2,190,293
-7.4
A13, 000.00
.236148
97.53
ENERAL CITY
62,927,257
3.8
413,000.00
3.569792
1,474.32
19,849,713
1.2
413,000.00
6.070900
2,507.28
IF RECEIPT IS REQUIRED SEND SELF ADDRESSED YEARLY
TAX ROYAL
STAMPED ENVELOPE AND ENCLOSE THIS BILL. 1 $4, 079.13
IF FULL YEARLY TAX TOTAL IS PAID IN ONE PAYMENT DISCOUNTED -
RV A4A RCR In THE DISCOT INTF.D TOTA T. WOTILI) BE TOTAL
$3, 987.35
2020 SARATOGA
City ,x County Tax Bill
SB/L
179.21-2-19
41 QUARTER
PAYMENT
1,019.78
DUE DECEMBER 1, 2020
If not Paid by December 1"
penalties will accrue.
See reverse side
for penalty schedule.
RFTTIRNTHIc CTriuW on1.rcw
n o
m O
N O
a m
N O
y
T
<
O O
N
C
1
N
V
y?
Oi
T
°
UUm
m N
e G
VJ Q w
(n
O z m m
Y
m o0 0o S y
i
W
Y
3 o�
�PGE
U O G
O
� o
T
A m L Y
C y
Y O �
°
Y y O
ja
P U a
.0
Y c4
ti
Y
0
xl'7a.�8 a �a
E o
O W Q Y y Y
3
N Z
m ~ > ^ ~ Y
V
Q m
m
VJ W p 0
+ Q }
z z>
a_ N Cl
C �' p,
w r
U
Q
N O a g o m
N y
Q Y R W
> �
cv, E E O Y 3
X 2 abi Y Q e� Y
+
Z
m y+j
3 z N
tl Om
�dE
—==aWU)
3 �xoo
70m
ooNN
�° B
w
I
a
d
o m m o
0 o N o
'y I fi m O
6d
n �• N l0
`o
vi 9 W F
ratoga Springs City School District
19 - 2020 School Tax
Fiscal Year Ending 06/30/20 ' Warrant Date 09104119
Saratoga Springs City SO
PO Box 378
Saratoga Springs, NY 12866
New Online Payment Option
Infotaxonline.com
Waite Theodore J III
Waite Barbara J
2 Stable Ln
Saratoga Springs, NY
School Tax Office M-F 9-3:30
3 Blue Streak Blvd - HS Campus
OR ON TIME with colored STUBS
at Adirondack Trust Co or
Saratoga National Bank
12866
Property Taxpaver's Bill of Rights
Full Market Value as of July 1, 2018:
Total Assessed Value as of March 1, 2019:
The Uniform Percentage of Value used to establish assessments was:
Exemption Value Tax Purpose Full Value Est.
Bill No. 005533
IIN�I��IA�I�
`119 005533 0'
TAX COLLECTOR SHELLI SAUPE
District website: Samtogaschools.org
Receipts 8 Online payments: Infotaxonline.com
E-mail: Tax_office@saratogaschools.org
Phone: (518)693-1455
INSTALLMENT 1 - DUE OCTOBER 4, 2019
INSTALLMENT 2 - DUE FEBRUARY 4, 2020
$655,556
$413,000
az nnoi
Total School Budget: $129,447,782
Total District Tax Levy: $86,321,878
Estimated State Aid: $33,063,033
NYS Taxation and Finance School District Code 562
in mange trom
Taxing Purpose Total Tax Levy Prior Year
Saratoga Springs CSD 86.321,878 3.0%
Library Tax 5,203,516 2.0%
S/B/L 411501 179.21-2-19
Address: 85 Nelson Ave
Town of: Saratoga Springs
School: 411500 - Saratoga Springs CSD
Acres: 0.35 Roll Section: 1
Bank:
Rate per $1000
Taxable Value or Units or Per Unit Tax Amount
413,000.00 16.824346 6,948.45
413,000.00 1.014178 418.86
TOTAL TAXES $7,367.31
OWNERSHIP INFORMATION PARCEL NO: 179.21-2-19
HERMAN, DAVID B Mail:
85 NELSON AVE
85 NELSON AVE
INSIDE NY 12866-5211
SARATOGA SPRINGS NY 12866-5211
PHONE NUMBER:
COUNTY: SARATOGA CENSUS TRACT:
0611.00
PROPERTY CLASS: -136-_THROE FAkLY YEAR-ROUND
.RESIDENCE . -
SALE INFORMATION Sale Date Price $
0 Deed Date
Arms Length N Libre 1060 Page
199 #Total Parcels
Seller Buyer Personal Property
PRIOR
LEARMS
SALES PRICE DATE SELLER
NGTH
BUYER
No sale history in database for this parcel.
STRUCTURAL INFORMATION LOT INFORMATION
TAX INFORMATION
Square Feet 3,575 Lot Size Dim.: 51.0ox333.50
Tax ID# 179.21-2-19
Sqft. 1st Floor 1,865 Land SQFT 17,009
Assessed Value $ 413,000
Sqft. 2nd Floor 1,710 Lot Size Acres 0.35
Land Assesment $ 130,000
Fin. Basement Sqft. 0 Zoning UR2
School Tax $ 6,121
Year Built 1890 Nbad Code 15120
County/Town Tax $ 1,210
Bldg Style OLD STYLE School District 411500 - SARATOGA
City/Village Tax $ 2,474
# Units 3 SPRINGS
Total Tax $ 9,805
# Stories 2.00 Desirability TYPICAL
Full Tax Value $ 503,658
# Baths 4 FULL Water Front N
Equalization Rate 0.82
# Bedrooms 6 Sewer COMMERCIAL/PUBLIC
Prior Tax ID# 120.-20-7
# Fireplaces 0 Water COMMERCIAL/PUBLIC
Full Land Value $ 158,536
# Kitchens 3 Utilities GAS/ELECTRIC
GAR-1.5 ATT, Nbad. Rating AVERAGE
BUILT:3201, Nbad. Type URBAN
*The calculated tax amounts are not
Garage Type 732 SQFT, # Res. Sites 1
exact. No special district tax amounts
CNDNORMAL,
or exemptions have been included. All
# Comm. Sites 0
numbers are estimated based on
GRADE: C Swis Code 411501
town values. Taxes should be verified
Garage Bays 1
directly from the local tax collector.
Cooling Detail NONE
Heat Type HEAT: (HOT AIR)
Updated:02/05/2013 10:02 am
FUEL:(GAS)
Exterior ALUM/VINYL
Condition NORMAL
Basement Type PARTIAL
EXEMPTIONS:
BASIC STAR 1999-2000
IMPROVEMENTS:
(1) PORCH -OPEN, BUILT 2003, 0 SQFT, CONDITION NORMAL
(1) PORCH-COVERD, BUILT 1890, 132.00 SQFT, CONDITION NORMAL
(1) GAR-1.5 ATT, BUILT 2001, 732.00 SQFT, CONDITION NORMAL
(1) PORCH -UP OPN, BUILT 2003, 40.00 SQFT, CONDITION NORMAL
(1) PORCH -UP OPN, BUILT 2003, 0 SQFT, CONDITION NORMAL
(1) PORCH -SCREEN, BUILT 2003, 40.00 SQFT, CONDITION NORMAL
Note: Display indicates first residential site and up to four improvements.
real-info.com makes no warranty or guarantee conceming the accuracy or reliability of the content contained in Iltis site. Information is
obtained from many sources. real-info.com shad[ not be liable for errors contained herein or for any damages in connection with the use of
the information contained herein.
NJ
00
n
N
N
O
O
F,
0
XI m
W
m
a
o o e
CD
O n g
M m
r
x
o n
co
f
N
co
E
L
N
l0
o
�
w p m rn
m
W
d Q O
d
t O d
U
Q
O
n O ESN
VJ
& O C
W
N
O
C
O
X
o
0 0
j o. o0 0
Fa-
tCl E
in E
E
j:
�
Q
F
V N
O
S2y d
N
.N
-
l0 �
0
a d
N x 0
O]
F`p
mo F
F a
N O N
0 O x
E
x F
O
«U)
d n N
JU a
d
0 >- F-
c O
i' Z Cn
U m
i
d
J 6
x m m
pC
F
O
Q
�
M
U
w
y
O)
C
O)
U)
N
N
N m p
T
a
q
c CO n
N 0
� o
o o
d U
Z m N
,N
O1
vmigv
'n
o
. n
N O
p� m
C o r
C y
N
Short Environmental Assessment Form
Part l - Project Information
Instructions for Completing
Part 1 — Project Information. The applicant or project sponsor is responsible for the completion of Part 1. Responses become part of the
application for approval or funding, are subject to public review, and may be subject to further verification. Complete Part l based on
information currently available. If additional research or investigation would be needed to fully respond to any item, please answer as
thoroughly as possible based on current information.
Complete all items in Part 1. You may also provide any additional information which you believe will be needed by or useful to the
lead agency; attach additional pages as necessary to supplement any item.
Part 1 — Project and Sponsor Information
Theodore Waite III
Name of Action or Project:
Waite Zoning Application
Project Location (describe, and attach a location map):
85 Nelson Avenue, Saratoga Springs, NY 12866
Brief Description of Proposed Action:
Application for use variance to permit premises to be used as a two family residence.
Name of Applicant or Sponsor:
Telephone: 518-441-6939
Theodore Waite III
E-Mail: theowaite@aol.com
Address:
85 Nelson Avenue
City/PO:
State:
Zip Code:
Saratoga Springs
NY
12866
1. Does the proposed action only involve the legislative adoption of a plan, local law, ordinance,
NO
YES
administrative rule, or regulation?
❑
If Yes, attach a narrative description of the intent of the proposed action and the environmental resources that
may be affected in the municipality and proceed to Part 2. If no, continue to question 2.
2. Does the proposed action require a permit, approval or funding from any other government Agency?
NO
YES
If Yes, list agency(s) name and permit or approval:
❑�
❑
3. a. Total acreage of the site of the proposed action? .35 acres
b. Total acreage to be physically disturbed? o acres
c. Total acreage (project site and any contiguous properties) owned
or controlled by the applicant or project sponsor? 7e acres
4. Check all land uses that occur on, are adjoining or near the proposed action:
❑✓ Urban ❑ Rural (non -agriculture) ❑ Industrial ❑ Commercial ❑ Residential (suburban)
❑ Forest ❑ Agriculture ❑ Aquatic m Other(Specify):
❑ Parkland
Pagel of 3 SEAF 2019
5. Is the proposed action,
a. A permitted use under the zoning regulations?
b. Consistent with the adopted comprehensive plan?
NO
YES
N/A
❑�
❑
❑�
❑
❑
❑
6. Is the proposed action consistent with the predominant character of the existing built or natural landscape?
NO
YES
7. Is the site of the proposed action located in, or does it adjoin, a state listed Critical Environmental Area?
If Yes, identify:
NO
YES
Z
❑
8. a. Will the proposed action result in a substantial increase in traffic above present levels?
b. Are public transportation services available at or near the site of the proposed action?
c. Are any pedestrian accommodations or bicycle routes available on or near the site of the proposed
action?
NO
YESRI
❑
❑
❑
❑
9. Does the proposed action meet or exceed the state energy code requirements?
If the proposed action will exceed requirements, describe design features and technologies:
NO
YES
10. Will the proposed action connect to an existing public/private water supply?
If No, describe method for providing potable water:
NO
YES
❑
✓❑
11. Will the proposed action connect to existing wastewater utilities?
If No, describe method for providing wastewater treatment:
NO
YES
❑
❑
12. a. Does the project site contain, or is it substantially contiguous to, a building, archaeological site, or district
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?
b. Is the project site, or any portion of it, located in or adjacent to an area designated as sensitive for
archaeological sites on the NY State Historic Preservation Office (SHPO) archaeological site inventory?
NO
YES
❑
✓❑
❑
13. a. Does any portion of the site of the proposed action, or lands adjoining the proposed action, contain
wetlands or other waterbodies regulated by a federal, state or local agency?
b. Would the proposed action physically alter, or encroach into, any existing wetland or waterbody?
If Yes, identify the wetland or waterbody and extent of alterations in square feet or acres:
NO
YES
21
❑
❑
❑
Page 2 of 3
14. Identify the typical habitat types that occur on, or are likely to be found on the project site. Check all that apply:
[]Shoreline ❑ Forest ❑ Agricultural/grasslands ❑ Early mid -successional
❑Wetland ❑ Urban ❑ Suburban
15. Does the site of the proposed action contain any species of animal, or associated habitats, listed by the State or
Federal government as threatened or endangered?
NO
YES
❑
❑
16. Is the project site located in the 100-year flood plan?
NO
YES
F7
❑
17. Will the proposed action create storm water discharge, either from point or non -point sources?
If Yes,
a. Will storm water discharges flow to adjacent properties?
b. Will storm water discharges be directed to established conveyance systems (runoff and storm drains)?
If Yes, briefly describe:
NO
YES
r7
❑
❑
❑
❑
18. Does the proposed action include construction or other activities that would result in the impoundment of water
or other liquids (e.g., retention pond, waste lagoon, dam)?
If Yes, explain the purpose and size of the impoundment:
NO
YES
❑
❑
19. Has the site of the proposed action or an adjoining property been the location of an active or closed solid waste
management facility?
If Yes, describe:
NO
YES
El
20.Has the site of the proposed action or an adjoining property been the subject of remediation (ongoing or
completed) for hazardous waste?
If Yes, describe:
NO
YES
❑
❑
I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF
MY KNOWLEDGE
Applicant/ nsor/n e: � 0 !P lo 60At � Date:
Signature: Title: d&_ 1di J
u
PRINT FORM Page 3 of 3