Name of Applicant or Sponsor *

First Name

Last Name

Phone Number *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

1. Does the proposed action only involve the legislative adoption of a plan, local law, ordinance, administrative rule, or regulation? *

Yes

No

2. Does the proposed action require a permit, approval or funding from any other government agency? *

Yes

No

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

Parkland

Aquatic

Other

5a. Is the proposed action a permitted use under the zoning regulations? *

Yes

No

N/A

5b. Is the proposed action consistent with the adopted comprehensive plan? *

Yes

No

N/A

6. Is the proposed action consistent with the predominant character of the existing built or natural landscape? *

Yes

No

7. Is the site of proposed action located in, or does it adjoin, a state listed Critical Environment Area? *

Yes

No

8a. Will the proposed action result in a substantial increase in traffic above present levels? *

Yes

No

8b. Are public transportation services available at or near the site of the proposed action? *

Yes

No

8c. Are any pedestrian accommodations or bicycle routes available on or near the site of the proposed action? *

Yes

No

9a. Does the proposed action meet or exceed the state energy code requirements? *

Yes

No

10a. Will the proposed action connect to an existing public/private water supply? *

Yes

No

11a. Will the proposed action connect to existing wastewater utilities? *

Yes

No

12a. Does the site contain, or is it substantially contiguous to, a building, archeological 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? *

Yes

No

12b. Is the project site, or any portion of it, located in or adjacent to an area designated as sensitive for archeological sites on the NY State Historic Preservation Office (SHPO) archeological site inventory? *

Yes

No

13a. Does any portion of the proposed action, or lands adjoining the proposed action, contain wetlands or other waterbodies regulated by a federal, state, or local agency? *

Yes

No

13b. Would the proposed action physically alter, or encroach into, any existing wetland or waterbody? *

Yes

No

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? *

Yes

No

16. Is the project site located in the 100-year floodplain? *

Yes

no

17a. Will the proposed action create storm water discharge, either from point or non-point sources? *

Yes

No

17b. If you answered “yes” to 17a, will storm water discharges flow to adjacent properties?

Yes

No

17c. If you answered “yes” to 17a, will storm water discharges be directed to established conveyance systems (runoff and storm drains)?

Yes

No

18a. Does the proposed action include construction other activities that would result in the impoundment of water or other liquids (e.g., retention pond, waste lagoon, dam)? *

Yes

No

19a. Has the site of the proposed action or adjoining property been the location of an active or closed solid waste management facility? *

Yes

No

20a. Has the site of the proposed action or adjoining property been the subject of remediation (ongoing or completed) for hazardous waste? *

Yes

No

CERTIFICATION OF INFORMATION ACCURACY *

I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE

Today's Date *

MM

DD

YYYY