Vermont Agency of Natural Resources Regional Offices

Regional Engineers Wastewater Management Div. Districts #1, 8 & 9 (Bennington, Rutland, Addison Cty.) 450 Asa Bloomer State Office Building Rutland, VT 05701 Tel. 786-5900 Districts #2 & 3 (Windham and Windsor Cty.) 100 Mineral Street, Suite 305 Springfield, VT 05156 Tel. 885-8855 Districts #4 & 6 (Chittenden, Franklin, Grand Isle Cty.) 111 West Street Essex Jct., VT 05452 Tel. 879-5656 Districts #3A and 5 (Orange, Lamoille, Washington Cty.) 5 Perry St., Suite 80 Barre, VT 05641 Tel. 476-0190 District #7 (Caledonia, Essex, Orleans Cty.) 1229 Portland Street, Suite 201 St. Johnsbury, VT 05819 Tel. 751-0130

District Wildlife Biologists Dept. of Fish & Wildlife District #1 (Windham and Windham Cty.) 100 Mineral Street, Suite 305 Springfield, VT 05156 Tel. 885-8855 District #2 (Bennington and Rutland Cty.) 217 Sanitorium Road, West Wing Pittsford, VT 05763 Tel. 483-2172 District #3 (Orange, Lamoille, Washington Cty.) 5 Perry St., Suite 40 Barre, VT 05641 Tel. 476-0199 District #4 (Addison, Chittenden, Franklin, Grand Isle Cty.) 111 West Street Essex Jct., VT 05452 Tel. 878-1564 District #5 (Orleans, Essex, Caledonia Cty.) 1229 Portland Street, Suite 201 St. Johnsbury, VT 05819 Tel. 751-0100

District Fisheries Biologist Dept. of Fish & Wildlife District #1 100 Mineral Street, Suite 305 Springfield, VT 05156 Tel. 885-8855 District #2 317 Sanitorium Road, West Wing Pittsford, VT 05763 Tel. 483-2172 District #3 3696 Roxbury Road Roxbury, VT 05669 Tel. 485-7566 District #4 111 West Street Essex Jct., VT 05452 Tel. 878-1564 District #5 1229 Portland Street, Suite 201 St. Johnsbury, VT 05819 Tel. 751-0100

County Foresters, Dept. of Forests, Parks, and Recreation Addison County 68 Catamount Park, Suite C Middlebury, VT 05753 Tel. 388-4969 Bennington County 478 Shaftsbury State Park Road Shaftsbury, VT 05262 Tel. 375-1217 Caledonia/Essex Counties 1229 Portland Street Suite 201 St. Johnsbury, VT 05819-2099 Tel. 751-0110 Chittenden County 111 West Street Essex Jct., VT 05452 Tel. 879-5694 Franklin/Grand Isle Counties 278 S. Main St. St. Albans, VT 05478-1866 Tel. 524-6501 Lamoille County 29 Sunset Dr., Suite 1 Morrisville, VT 05661-8331 Tel. 888-5733 Orange County 5 Perry St., Suite 20 Barre, VT 05641 Tel. 476-0173 Orleans County 338 Highland Ave. Newport, VT 05855 Tel. 334-7325 Rutland County 317 Sanitorium Road West Wing Pittsford, VT 05763 Tel. 483-2730 Washington County 5 Perry St., Suite 20 Barre, VT 05641 Tel. 476-0172 Windham County 157 Old Gilford Rd. Brattleboro, VT 05301 Tel. 257-7967 Windsor County 212 Holiday Dr., Suite 5 White River Jct., VT 05001 Tel. 296-7630

ACT 250 LAND USE PERMIT-- APPLICATION COVER SHEETS

NAMES: 1. Applicant(s) Name ____________________________________________________________ Address____________________________________________________________________ ______________________________ email: _____________________ Phone ____________ Legal form: [ ] individual [ ] partnership (attach list of partners) [ ] municipal gov't [ ] state gov't [ ] corporation: date formed ______ place formed_____________ date registered in Vt. ________ Legal interest in land: [ ] ownership in fee simple [ ] lease agreement [ ] contract to purchase [ ] other:_______________________________________ 2. Landowner(s) Name_____________________________________________________________ Address_______________________________________________________________________ _______________________________ email: ______________________ Phone ____________ 3. Names of others with significant interest(s) in the property: Name _____________________________________ Address ______________________________________________________________________ Phone ___________________ Description of Interest (easement, right-of-way, etc.): __________ _____________________________________________________________________________

4. Contact person________________________________________________________________ Address_______________________________________________________________________ _______________________ email: ___________________ Phone_________FAX___________ PROJECT DESCRIPTION: 5. Type: [ ] new project; [ ] expansion of project previously exempt from Act 250; [ ] amendment of existing Act 250 permit or permit condition (permit #_______________) PLEASE NOTE: If you are applying to amend a permit condition which was included to resolve an issue critical to the district commission's or the board's issuance of a prior permit, please contact the District Coordinator to determine whether you need to address the Stowe Club Highlands analysis. Also see Act 250 Rule 34(E) (www.nrb.state.vt.us/lup/rules.htm) 6. General description of project (include number and size of buildings; use of buildings; number of lots; length of roads; etc.): _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 7. Construction duration______________; Duration of Permit Request (if project involves earth extraction or solid waste disposal) ___________________________ LAND: 8. Total acres owned or controlled by applicant and landowner at project site _______; Acres in additional easements or rights-of-way ________ ; Acres committed to this project ____________

9.

Location: Town____________ Road ________________nearby landmark__________________ State Plane Coordinates (NAD83):_______________ ________________ (preferable) or Latitude_______ Longitude_______ Coordinates Note: Choose a location as close as possible to the area where construction is to occur.

10. Deed(s):Grantee's name as recorded:_______________________________________________ Book(s) _____ Page(s)_____Date(s)___________ Town ___________ County _____________ OTHER INFORMATION: 11. Check below if you are concurrently applying for any of the following permits from the Agency of Natural Resources: [ ] Potable Water Supply and Wastewater System Permit; [ ] Stormwater Discharge Permit; [ ] Construction General Permit; [ ] Public Water System Permit to Construct; [ ] Conditional Use Determination; [ ] Air Pollution Control Permit; [ ] other __________________. 12. Have you received local zoning and/or subdivision approval? [ ] yes [ ] pending [ ] none needed 13. [] [] [] [] [] [] [] Attach the following unless waived by the District Coordinator: location map (U.S.G.S. map preferred) [ ] Municipal Impact Questionnaire site plan or plot plan (see instructions) [ ] School Impact Questionnaire building elevation drawings [ ] Supporting documents as recommended in (excluding single family homes) Schedule B or as needed schedule A - fee information [ ] Act 250 fee (payable to State of Vermont) schedule B - Act 250 information [ ] A copy of any Act 250 master permits applicable schedule E - adjoiner information to this project schedule F - certification of service

SIGNATURES: 14. I hereby swear that the information provided above or attached to this application is true and accurate to the best of my knowledge. Signature of applicant(s)____________________________ Date ______________. Please clearly print name(s) ______________________________________________ 15. I hereby certify that I understand that I must not commence construction, demolition, remodeling or commercial use of the property as described in Act 250 Rule 2(C) until I have received an Act 250 Land Use Permit as required by 10 V.S.A. Sec. 6081. Signature of applicant(s)_____________________________ Date ______________. 16. I hereby authorize the processing of this application for the above project on land(s) that I own, control, or have significant property interest in. (attach letter if easier) Signature of landowner(s) ____________________________ Date_______________. Please clearly print name(s) _______________________________________________

DISTRIBUTION OF APPLICATION PACKAGE: 17. SUBMIT THE ORIGINAL AND THREE COPIES TO THE DISTRICT COORDINATOR. 18. SUBMIT ONE COPY EACH TO THE MUNICIPALITY, MUNICIPAL PLANNING COMMISSION, REGIONAL PLANNING COMMISSION, AGENCY OF NATURAL RESOURCES (Division of Regulatory Management & Act 250 Review, Agency of Natural Resources, 103 South Main Street, Ctr. Bldg., 3rd Floor, Waterbury, VT 05671-0301), AND TO ANY ADJOINING MUNICIPALITIES AND PLANNING COMMISSIONS IF THE PROPERTY IS LOCATED ON A TOWN LINE.

SCHEDULE A Fee Information (Effective July 1, 2010)

Submit with the application a check payable to the "State of Vermont". Municipal and state agency projects are exempt from fees but should still report construction costs on this form. Not-for-profit organizations are not exempt. Calculate the fee using the following table: Note: All lines on the schedule must be filled out. If a line does not apply, or if there is no associated cost, enter 0. An incomplete schedule will result in a delay in application processing. 1) 2) Number of lots to be created ______ x $100.00 = Gravel Pits: $.20/cubic yard of the proposed maximum rate of annual extraction = Construction costs:* Site preparation . . . . . . . . . . Buildings: a) sq. ft. ___________ b) $ per sq. ft. ______ Total (a x b) . . . . . . Roads and parking . . . . . . . . Utilities . . . . . . . . . . . . . . . . . Off-site improvements . . . . . . Landscaping . . . . . . . . . . . . . Other _____________. . . . . Total costs: 4) $____________ $ ____________

$_____________

3)

$____________ $____________ $____________ $____________ $____________ $____________ $____________ x 0.00540 = Total Fee (Sections 1 + 2 + 3) =

$_____________** $_____________***

* For residential subdivisions, include the estimated construction cost of all improvements proposed to be constructed by the applicant or a related person or entity, including common facilities, infrastructure, dwellings, and other. (For more information, see definition of "person" at 10 V.S.A. 6001(14).) (www.nrb.state.vt.us/lup/statute.htm) ** For projects exceeding $15,000,000 in total cost, multiply the first $15,000,000 in costs X .00540 and multiply the balance of the costs X .00250. See 10 V.S.A. 6083a (www.nrb.state.vt.us/lup/statute.htm) for the complete schedule of fees. *** Minimum fee of $150 for new applications Minimum fee of $50 for amendment applications Maximum total application fee is $150,000.00 Treat expansions of approved projects as new applications.

I attest by my signature that the above is true to the best of my knowledge:

__________________________________________ (signature of applicant or agent)

Certificate of Actual Construction Costs

Effective July 1, 2010 Print Permittees Name_________________________ Permit # __________ Date _________
The permittee(s) shall file this certificate of actual construction costs pursuant to 10 V.S.A. 6083a(g) within one month after construction has been substantially completed or two years from the date of this permit, whichever shall occur first. (Application for extension of time for good cause shown may be made to the District Commission.) If actual construction costs exceed the original estimate, a supplemental fee based on actual construction costs must be paid at the time of certification. Upon request, the permittee(s) shall provide all documents or other information necessary to substantiate the certification. Pursuant to 10 V.S.A. 6083a(g), failure to file the certification or pay any supplemental fee due are grounds for permit revocation. 1) 2) Number of lots created ______ x $100.00 = Gravel Pits: $.20/cubic yard of the proposed maximum rate of annual extraction = Actual Construction costs:* Site preparation . . . . . . . . . . $____________ $ ____________

$___________

3)

Buildings: a) sq. ft. ___________ b) $ per sq. ft. ______ Total (a x b) . . . . . . . . $____________ Roads and parking . . . . . . . $____________ Utilities . . . . . . . . . . . . . . . . $____________ Off-site improvements . . . . $____________ Landscaping . . . . . . . . . . . . $____________ Other _____________. . . . $____________ Total Actual Construction Costs: $____________ x 0.00540 = $_____________ 4) 5) Total Fee (Sections 1+2+3) Original Fee Submitted = $_____________*** = $_____________ = $_____________

6) Supplemental Fee to be submitted to Natural Resources Board (Section 4 - Section 5)

* For residential subdivisions, include the estimated construction cost of all improvements proposed to be constructed by the applicant or a related person or entity, including common facilities, infrastructure, dwellings, and other. (For more information, see definition of "person" at 10 V.S.A. 6001(14).) (www.nrb.state.vt.us/lup/statute.htm) ** For projects exceeding $15,000,000 in total cost, multiply the first $15,000,000 in costs X .00540 and multiply the balance of the costs X .00250. See 10 V.S.A. 6083a (www.nrb.state.vt.us/lup/statute.htm) for the complete schedule of fees.

Continues on Page 2

Certificate of Actual Construction Costs

Page 2
*** Minimum fee of $150 for new applications Minimum fee of $50 for amendment applications Maximum total application fee is $150,000.00 I attest by my signature under 13 V.S.A. 3016 (FALSE CLAIM) that the above is true to the best of my knowledge: __________________________________________ (signature of applicant or agent) This certificate of actual construction costs and any supplemental fee (by check payable to the "State of Vermont") should be mailed to: Natural Resources Board, National Life Records Center Building, National Life Drive, Montpelier, VT 05620-3201.

SCHEDULE E Adjoiner Information

Submit with the application a list of all adjoining landowners with mailing addresses. An "adjoiner" is a person or organization which owns or controls land or easements on lands which physically abut the tract or tracts of land on which your project is located. Be certain to include landowners on the opposite sides of highways, railways, and rivers. Also include homeowner associations, utility companies, and others with significant legal interest in the project land. It is very helpful if you indicate the location of each adjoiner on your site plan. If you do not provide a list which is thorough and up-to-date, your application could be delayed because of improper notice distribution! Please note: For lists which include more than 20 adjoining landowners, our administrative staff appreciates receiving the list on mailing labels to facilitate the notification process. Thank you.

NAME

MAILING ADDRESS WITH ZIP CODE

_________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ Attach additional sheets if necessary.

SCHEDULE F Certification of Service and Notice of Application

You are required by 10 V.S.A. 6084 to send notice and a copy of your application to the municipality, the municipal and regional planning commission in which the land is located, the Vermont Agency of Natural Resources (Division of Regulatory Management & Act 250 Review, Agency of Natural Resources, 103 South Main Street, Ctr. Bldg., 3rd Floor, Waterbury, VT 056710301), and any adjacent Vermont municipality, municipal or regional planning commission if the land is located on a boundary on or before the date of filing your application with the district commission. You are also required to send notice and a copy of your application to the solid waste management district in which the land is located, if the development or subdivision constitutes a facility pursuant to subdivision 6602(10) of Title 10 V.S.A. Chapter 151. You must also post a copy of the notice in the town clerks office of the town or towns where the land is located. A notice form is attached for your convenience. In order to verify that the statutory parties to the application have received copies of the application and thus avoid delay caused by improper distribution of the application, have a representative of the parties sign this form when they receive the application. You may, in the alternative, send copies of the notice and application by Certified U.S. Mail, UPS/Federal Express, or courier and list the names below. Applicant(s) Name _________________________________________________________________ I, the undersigned, have received a copy of an Act 250 application for the above applicant(s). ____________________________________________ ______________________ for the selectmen, aldermen, or trustees date ____________________________________________ ______________________ for the municipal planning commission date ____________________________________________ ______________________ for the regional planning commission date ___________________________________________________________________ for the Agency of Natural Resources date ____________________________________________ ______________________ for an adjacent municipality, if any* date ____________________________________________ _____________________ for an adjacent planning commission, if any* date ____________________________________________ _____________________ for an adjacent regional planning commission, date if any* ____________________________________________ ______________________ for regional solid waste management district, date if applicable I hereby certify that I have forwarded a complete copy of this application to each of the parties entitled to notice pursuant to 10 V.S.A. Section 6084 and that I have posted a copy of the notice of application in the town clerks office(s). ____________________________________________ __________________ Applicant(s)/Agent Signature Date * Attach additional sheets if more than one town is adjacent to the project lands.

Schedule F - Notice
Note To Applicants: This notice must be included with all copies of the application. You must also post, or cause to be posted, a copy of this notice in the town clerks office of the town or towns wherein the land proposed for subdivision or development lies. Notice of Act 250 Application By application dated _____________, (name and address of applicant) ________________________________________________________________________________ __________________________________________________________________filed an application pursuant to 10 V.S.A. 6001 et seq. (Act 250") to: (description of project including road location and Town) ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ A copy of this application may be reviewed at the Town Offices, Town of _______________, Vermont (contact the Town Clerk or Administrator). Signature _______________________ Date ____________ In the event you wish to receive further notice concerning this application, please contact the district office for your area: Environmental Comm. Districts #1 and 8 440 Asa Bloomer State Office Building 4th Floor 88 Merchants Row Rutland, VT 05701 (Tel. 786-5920) Environmental Comm. Districts #2 and 3 100 Mineral Street Suite #305 Springfield, VT 05156 (Tel. 885-8855) Environmental Comm. Districts #4, 6 and 9 111 West St. Essex Jct., VT 05452 (Tel. 879-5614) Environmental Comm. District #7 1229 Portland St. Suite 201 St. Johnsbury, VT 05819 (Tel. 751-0120)

Environmental Comm. District #5 5 Perry Street, Suite 60 Barre, VT 05641 (Tel. 476-0185)

SCHEDULE G
Act 250 Participants
Please list below the name and town of residence for all persons not listed on the Cover Sheet who are affiliated with the applicant(s) for the project or who may be involved in presenting the applicants case as an agent or representative. This information will help District Commissioners to determine if they have potential conflicts of interest. Full and early disclosure of this information will help to avoid delays later in the process. Thank you. Additional Applicants, Landowners, or Persons Affiliated with the Applicant for the Project: [Examples of affiliation include partners, directors, officers, court appointed guardians, family members (e.g. spouse, parents, children), entity members, stockholders (if share is greater than 5%), or any professional whose benefit from the proposed Project indicates more than an agency relationship with the Applicant(s). If you have questions, please contact the district coordinator.] Name (Print) Town of Residence / Incorporation

_________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Consultants, Attorneys, or other Agents of the Applicant: Name (Print) Town of Residence

_________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________

Witnesses for the Applicant (if known at this time): Name (Print) Town of Residence

_________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________

ACT 250 SCHEDULE B - SHORT FORM Response to the 10 Criteria and Subcriteria
This form is designed primarily for projects with limited potential for significant adverse impact under the criteria of Act 250. If you have questions about whether to use this form or the regular Schedule B, please contact the Act 250 District Coordinator for assistance. The Guide to Applying for an Act 250 Land Use Permit, available at the District Environmental Offices or on-line (www.nrb.state.vt.us/lup/publications.htm), provides additional information about how to answer the questions below. Criterion 1) Demonstrate that the project will not cause undue air pollution: a) What type of heating systems or other fuel-burning systems are proposed? _________________________________________________________________________ b) What process emissions, noxious odors or sources of noise will result from the project, and what measures are proposed for control? _________________________________________________________________________ c) What methods will be used to control dust during and after construction? _________________________________________________________________________ d) Does your project require an ANR Air Pollution Control Permit? [ ] Yes [ ] No. If yes, have you applied to the ANR Air Pollution Control Div. (241-3840)? [ ] Yes [ ] No. Criterion 1A) Headwaters: Demonstrate that the project will meet any applicable environmental conservation department regulations regarding any reduction of the quality of ground or surface waters in a headwaters area: a) Is your project in a headwaters area? Headwaters contain steep slopes or shallow soils; drain 20 square miles or less; are watersheds for public water supplies; provide significant recharge to aquifers; or are above 1,500 feet. [ ] Yes [ ] No. If yes, contact District Coordinator. Criterion 1B) Waste Disposal: Demonstrate that the project will meet any applicable health or environmental conservation department regulations regarding the disposal of wastes and demonstrate that the project will not involve the injection of wastes or toxic substances into ground waters: a) What method of sewage disposal is proposed? _________________________________________________________________________ _________________________________________________________________________ b) Have you applied to the ANR Wastewater Management Division (see telephone numbers for ANR regional offices) for a Potable Water Supply and Wastewater System Permit to satisfy this criterion? [ ] Yes [ ] No. Permit #____________
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c) What is the acreage of the project site which will be disturbed during construction? ___ Acres. Show the limits of disturbance on the site plan. d) What is the acreage of the project site which will be permanently covered with buildings, roadways, parking areas, or other impervious areas as part of this project? ___ Acres. If your project is an amendment to a previously permitted project, indicate how many acres of impervious surface currently exist on the site: ___ Acres. Show all impervious surfaces on the site plan. e) How will stormwater runoff from the project be treated and disposed? Are you required to obtain a Stormwater Discharge Permit, Construction General Permit, or Multi-Sector General Permit? [ ] Yes [ ] No. If you are unsure, contact the ANR Water Quality Division (2413770) or visit the web site: www.vtwaterquality.org/stormwater.htm. _________________________________________________________________________ _________________________________________________________________________ f) Will hazardous materials (chemicals, pesticides, herbicides) be used or stored on site? [ ] Yes [ ] No. If so, describe the materials, type of storage and use. ________________________________________________________________________ ________________________________________________________________________ e) Indicate how construction debris, including stumps, will be disposed of without creating water pollution. If the project involves more than 10,000 square feet of building construction, renovation, or demolition, describe how construction and demolition waste prevention, reuse, and recycling will be incorporated into the project. (Include in the description items required to be recycled through local recycling ordinances, and, if appropriate, the environmentallyresponsible management of scrap metals, brick and concrete, wood, drywall, roofing, cardboard, plastics, and any other wastes.) The Agency of Natural Resources has developed a Waste Reduction Plan Template that applicants can use to describe their management plan. The Plan is available at: www.anr.state.vt.us/dec/wastediv/recycling/candd.htm. Additionally, information on reuse and recycling markets is available at the same site. Applicants may contact the ANR Solid Waste Program for guidance at 241-3444. _________________________________________________________________________ _________________________________________________________________________ Criterion 1C) Water Conservation: Demonstrate that the project will use the best available water conservation technology: a) Will any water be used for commercial or industrial manufacturing or processing? [ ] Yes [ ] No. Will any water be withdrawn from rivers, streams, or other bodies of water? [ ] Yes [ ] No. If the answer to either question is yes, describe extent of water use and conservation measures. Are any permit approvals required by the Agency of Natural Resources? _____________________________________________________________________
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Criterion 1D) Floodways: Demonstrate that the project will not endanger the health, safety and welfare of the public or of riparian owners during flooding: a) If any portion of the project is located within a Special Flood Hazard Area as designated on the most current National Flood Insurance Program (NFIP) maps (available for viewing at town offices in NFIP participating communities or at http://msc.fema.gov) or if any portion of the project is located within 100 feet of a perennial stream or river, show the location of the floodway and floodway fringe on the site plan and demonstrate that the project will be designed and constructed in accordance with NFIP regulations and will not be threatened by flooding or by the instability of the stream over time. The Secretary of the Agency of Natural Resources is responsible for determining the limits of the floodway and floodway fringe and the potential threats to the health, safety, and welfare of the public posed by stream flooding or instability (see 10 V.S.A. 6001(6&7) and 6086(a)(1)(D) http://www.nrb.state.vt.us/lup/statute.htm). This determination is made by reviewing the NFIP maps and by considering the potential erosion hazards of the stream channel. Questions relating to the NFIP maps should be addressed to the municipal Zoning Administrative Officer or to the ANR River Corridor Management Section, State NFIP Coordinator at 241-3759. For more guidance on determining Act 250 floodway limits, please review ANR's Procedure on ANR Floodway Determinations in Act 250 Proceedings and the accompanying Technical Guidance for Determining Floodway Limits Pursuant to Act 250 Criterion 1(D), (both available at: www.anr.state.vt.us/dec/waterq/rivers/htm/rv_floodhazard.htm) or contact the ANR River Corridor Management Section, Fluvial Erosion Hazard Coordinator at 241-1262. _________________________________________________________________________ _________________________________________________________________________ Criterion 1E) Streams: Demonstrate that the project will maintain the natural condition of any streams, when feasible: a) If the project is located near a stream or watercourse, what is the distance from the nearest disturbed area to the top of the streambank? Show streams and watercourses on a site plan. _________________________________________________________________________ b) Describe any construction that will disturb the stream bed or adjacent areas in any way. _________________________________________________________________________ _________________________________________________________________________ c) Will there be any disturbance of a stream or stream bank? [ ] Yes [ ] No. If so, a Stream Alteration Permit may be required. Contact the Stream Alteration Engineer with the ANR Water Quality Division (No. Vt.: 751-0129, So. Vt.: 786-5906). If a Stream Alteration Permit is required, what is the status of your application? _________________________________________________________________________
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Criterion 1F) Shorelines: Demonstrate that if the project is located along a shoreline, it complies with the four standards relating to the condition of the shoreline listed in b) below: a) Does the project involve development or subdivision on or near a river, lake, pond or reservoir shoreline? [ ] Yes [ ] No. If yes, describe the activity including distance between high water mark and any construction area. _________________________________________________________________________ b) Describe methods used to retain the shoreline in a natural condition, control erosion, screen the project from the waters, and allow continued public access to the waters.

Criterion 1G) Wetlands: Demonstrate that the project will meet applicable Water Resources Board regulations regarding any impacts on designated significant wetlands: a) Does the tract contain wetlands? [ ] Yes [ ] No. If yes, describe the wetlands and any disturbance that may occur within 50 ft. of the wetland. _________________________________________________________________________ ________________________________________________________________________ b) Is a Conditional Use Determination (CUD) from the ANR Water Quality Division (241-3770) required for work in the wetland or wetland buffer? [ ] Yes [ ] No. Contact the ANR Wetlands Biologist for further guidance. If a CUD is required, are you relying on the CUD to satisfy this Criterion? [ ] Yes [ ] No. _________________________________________________________________________ _________________________________________________________________________ Criteria 2 and 3) Water Supply: Demonstrate that the project has sufficient water available for its needs; and that the project will not cause an unreasonable burden on an existing water supply: a) How will water be supplied to the project and what are the demands? Is the water supply public or private? _________________________________________________________________________ _________________________________________________________________________ b) Is a Potable Water Supply and Wastewater System Permit from the ANR Wastewater Management Division required? [ ] Yes [ ] No. If yes, what is the status of your application? _________________________________________________________________________ c) Identify adjacent water supplies. Are there any anticipated impacts to existing private or public water supplies? ________________________________________________________________________
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Criterion 4) Soil Erosion: Demonstrate that the project will not cause unreasonable soil erosion and will not cause a reduction in the capacity of the land to hold water so that a dangerous situation results: a) Describe the terrain (including slope) in areas where earth work is proposed. Describe the nature and extent of ground disturbance proposed, including the sequence of construction activities. _________________________________________________________________________ _________________________________________________________________________ b) Describe what erosion control measures will be taken during construction to prevent eroded sediment from reaching a water body or adjoining property. (Include hay bale dams or silt fences, daily mulching, diversion ditches, sediment basins, etc.) _________________________________________________________________________ _________________________________________________________________________ c) Describe what permanent erosion control measures will be taken after construction to stabilize the site from continued erosion. (Include stone-lined ditches, grassed swales, paving, rip-rap, seeding mixtures, etc.) For more information about the elements of an erosion control plan see ANRs Erosion Prevention and Sedimentation Control Plan Checklist available at www.anr.state.vt.us/dec/waterq/stormwater/htm/sw_cgp.htm. _________________________________________________________________________ _________________________________________________________________________ d) How frequently will the erosion controls be inspected during construction and who will be accountable for their maintenance? _________________________________________________________________________ Criterion 5) Highways and Other Means of Transportation: Demonstrate that the project will not cause unreasonable congestion or unsafe conditions with respect to the use of highways and other means of transportation: a) Describe the access to the project. _________________________________________________________________________ b) Demonstrate there are sufficient parking spaces for the needs of the project. Show parking areas on the site plan. _________________________________________________________________________ c) How many one-way trips per day will the project generate? _________________________________________________________________________
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d) Describe the sight distances at the intersection of access points or driveways on state or town highways. ________________________________________________________________________ e) Indicate the speed limit on the adjacent town or state highway. _______________________ f) Has the town or state approved the project access? [ ] Yes [ ] No. If you are unsure whether a state approval is necessary, contact the Utilities Unit of the Vermont Agency of Transportation (VTrans)( 828-2653). Attach a copy of the approval.

Criterion 6) Educational Services: Demonstrate that the project will not cause an unreasonable burden on the ability of local governments to provide educational services: a) Estimate the number of additional students who may attend the local schools as a result of this project. ________________ b) Provide evidence that area schools will be able to accommodate these additional students. (Narrative response or School Impact Questionnaire) _________________________________________________________________________ Criterion 7) Municipal Services: Demonstrate that the project will not cause an unreasonable burden on the ability of local governments to provide municipal or governmental services: a) Check the municipal services that will be utilized: [ ] Police, [ ] Fire Protection, [ ] Solid Waste Disposal, [ ] Water Supply, [ ] Sewage Disposal, [ ] Road Maintenance, [ ] Ambulance. b) Attach letters from representatives of any of the services checked above which indicate that the services are available and will not be unreasonably burdened by the project or submit a completed Municipal Impact Questionnaire or explain why the project will not result in a burden on municipal services. _________________________________________________________________________ _________________________________________________________________________ Criterion 8) Scenic Beauty, Historic Sites, and Natural Areas: Demonstrate that the project will not have an undue adverse effect on the scenic or natural beauty of the area, aesthetics, historic sites, or rare or irreplaceable natural areas: a) Describe the tract (include terrain, existing vegetation and buildings, if any) surrounding area, and any natural areas. (Attach photos if available.) _________________________________________________________________________ _________________________________________________________________________
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b) Describe the proposed landscaping, including number, species, size of new plantings, and areas of existing vegetation to be retained: (Attach plan) _________________________________________________________________________ _________________________________________________________________________ c) From where will the project be visible? _________________________________________________________________________ _________________________________________________________________________ d) Describe exterior lighting including fixture numbers and types, pole heights, bulb type and location. _________________________________________________________________________ _________________________________________________________________________ e) Describe all exterior signs including materials, colors and type of illumination and size. _________________________________________________________________________ _________________________________________________________________________ f) Describe building exterior, including design, materials and colors. _________________________________________________________________________ _________________________________________________________________________ g) Indicate the location of any above-ground utility lines, street lights, and refuse storage areas or receptacles. (Show on plan) _________________________________________________________________________ h) Describe any recorded historic sites, including historic structures (more than 50 years old) or districts (i.e., on the State or National Register of Historic Places) located on the tract. Contact the Division For Historic Preservation (DHP) (828-3048) if you have any questions regarding any potential historic sites which might be affected by the project. _________________________________________________________________________ i) Is your project located on land that contains or is likely to contain a prehistoric Native American archeological site? [ ] Yes [ ] No. If you are unsure, contact the Vermont Division for Historic Preservation at 828-3048 or a professional archeologist. To help applicants determine whether a project is located on or near an archeological site, the DHP has developed the Environmental Predictive Model, available from the DHP or at: www.dhca.state.vt.us/DHP/programs/model.pdf. For more information about the DHPs role in
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the Act 250 process, review the Vermont Historic Preservation Act Rules, available from DHP or at: www.dhca.state.vt.us/DHP/general/rules.html. Criterion 8A) Wildlife and Endangered Species: Demonstrate that the project will not destroy or significantly imperil necessary wildlife or endangered species habitat: a) Does the project tract include any necessary wildlife habitat or endangered species? Contact the ANR Wildlife Biologist at the District Office to identify the resource. _________________________________________________________________________ b) Describe any impact the project will have on identified necessary wildlife habitat or endangered species (including any logging or land filling on the tract). _________________________________________________________________________ _________________________________________________________________________ Criterion 9A) Impact of Growth: Demonstrate that the project will not significantly affect the ability of the town and region to accommodate growth: a) For residential projects, indicate how many additional people may live in the project, what portion may be seasonal, and what percentage of the total population of the municipality these additional people represent. _________________________________________________________________________ b) For commercial or recreational projects provide information regarding anticipated employment growth, growth in personal income, retail sales growth, or growth in tourism. ________________________________________________________________________ c) For all projects, provide an estimate of the tax revenues the project will generate. This includes property tax revenues paid to the municipality as well as income tax, sales, and rooms and meals taxes paid to the state, if appropriate. _________________________________________________________________________ Criteria 9B) Primary Agricultural Soils: Demonstrate that the project will not reduce the agricultural potential of primary agricultural soils. Note: If your site contains or may contain primary agricultural soils, you must address this criterion. Please read the Criterion 9(B) section in the Guide to Applying for an Act 250 Land Use Permit before proceeding with the section below. The Guide is available on the Land Use Panels web site (www.nrb.state.vt.us/lup/publications.htm) or at the Act 250 District Offices listed at the beginning of the application form. a) Has the district commission previously issued findings regarding primary agricultural soils on your parcel? If so, please attach a copy of the findings or summarize the findings below, including the Act 250 case number. If the findings indicate that there are no primary agricultural soils on your parcel, you may continue with Criterion 9(C) below. If not, please continue with
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question b). ____________________________________________________________________________ ____________________________________________________________________________ b) Does your project involve any earth disturbance or subdivision of land? [ ] Yes [ ] No If No, you may proceed with Criterion 9(C) below. If Yes, continue with c) below. Contact the district coordinator if you have any questions. c) If your project involves earth disturbance or the subdivision of land, provide a summary of the soils on the entire project parcel in a matrix format showing: the number of acres of each type of soil on the parcel (use the soil type abbreviations and soil name); and the agricultural value group (1-11) for all soils listed.

(See the Guide to Applying for An Act 250 Land Use Permit for information, available at www.nrb.state.vt.us/lup/publications.htm, about soils mapping, the definition of primary agricultural soils, and for a sample soils matrix.) d) Does the project site contain primary agricultural soils (soils listed in agricultural value groups 17)? [ ] Yes [ ] No. If No, you do not need to continue with this section. If Yes, please submit the Criterion 9(B) Supplement, which is available from the Act 250 District Office or from the Land Use Panels web site (www.nrb.state.vt.us/lup/publications.htm). For more information about complying with this Criterion, please contact the Act 250 District Coordinator for assistance. Criterion 9C) Productive Forest Soils: Demonstrate that the project will not result in any reduction in the potential of productive forest soils: If your site may contain productive forest soils, you should read the Criterion 9(C) section in the Guide to Applying for an Act 250 Land Use Permit before proceeding with the section below. The Guide is available on the Land Use Panels web site (www.nrb.state.vt.us/lup/ publications.htm or at the Act 250 District Offices listed at the beginning of the application. a) Does the project site contain productive forest soils? [ ] Yes [ ] No. If there are no productive forest soils on the site, you do not need to answer any additional questions for this section. If productive forest soils exist, continue with question b) below. If you are unsure, a consulting forester or the County Forester for your area may be of assistance. (See listing in front of application.) b) If productive forest soils exist on the site, is the project site located in a designated growth center as defined at 24 V.S.A. 2491(12)(A)? [ ] Yes [ ] No c) If productive forest soils exist on the site, provide the following information: i) a site plan showing the location and number of acres of productive forest soils on the site (there is no minimum, so report all acreage) and the number of acres of productive forest soils to be impacted by the project, ii) whether the site is currently being managed for commercial forestry or has been managed for commercial forestry in the past, iii) the name, location, and type of neighboring agricultural or forestry operations, including leased farmland or forestland. ____________________________________________________________________________
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d) If the project is located outside a designated growth center, explain how the project has been planned to minimize the reduction of the potential of the productive forest soils through innovative land use design resulting in compact development patterns, so that the remaining forest soils on the project tract may contribute to a commercial forestry operation. ____________________________________________________________________________ ____________________________________________________________________________ e) If the project is located outside a designated growth center, does the applicant own or control any lands other than productive forest soils which are reasonably suited to the purpose of the project? [ ] Yes [ ] No Criteria 9D) and 9E) Earth Resources: Demonstrate that the project will not interfere with the future extraction of earth resources; and demonstrate that if the project involves the extraction of earth resources, it will not unduly harm the environment or neighboring land uses, and will be reclaimed for an alternative use: a) Are there any mineral or earth resources on the site with a high potential for extraction? [ ] Yes [ ] No. If yes, what kind? _________________________________________________________________________ b) Describe what measures are being taken to prevent interference with future extraction or processing of these earth resources. _________________________________________________________________________ c) If the project involves extraction of earth resources, describe the reclamation plans and what measures are being taken to prevent unduly harmful impacts associated with the extraction. _________________________________________________________________________ Criterion 9F) Energy Conservation: Demonstrate that the project reflects the principles of energy conservation and utilizes the best available technology for energy efficiency: a) Residential Buildings: Residential buildings three stories or less are subject to Vermonts Residential Building Energy Standards (RBES) (21 V.S.A. 266-267). Conformance with these standards creates a presumption of compliance with Criterion 9(F) (21 V.S.A. 266(d)). Will the project comply with the RBES? [ ] Yes [ ] No. For more information, contact the Vermont Residential Energy Code Hotline at 1-888-373-2255 or visit publicservice.vermont.gov/energy-efficiency/ee_energyefficiency.html. b) Commercial Buildings: Commercial buildings (all buildings which are not residential buildings three stories or less) are subject to Vermonts Commercial Building Energy Standards (CBES) (21 V.S.A. 268). The 2005 Vermont Guidelines for Energy Efficient Commercial Construction serves as the handbook for compliance with the CBES. The Guidelines can be found on the web site of the Vermont Department of Public Service (http://publicservice.vermont.gov/energy-efficiency/ee_commstandards.html) or by contacting the department at 828-4020. Will the project comply with the Guidelines? [ ] Yes [ ] No
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c) Please provide information about any additional energy conservation measures which will be incorporated into your project. ________________________________________________________________________ d) Would you agree to this permit condition: "The installation of electric resistance space heating or stand-alone electric domestic water heating equipment in any building subject to this permit is expressly prohibited without prior District Commission approval"? [ ] Yes [ ] No. Criterion 9G) Private Utilities: Demonstrate that any private utilities shared by two or more owners will not become a burden on the municipality if it must assume responsibility for them: a) Are any private shared utility systems proposed (i.e. water, sewer, stormwater, roads, etc.)? If yes, what are they and how will they be maintained? _________________________________________________________________________ Criterion 9H) Scattered Development: Demonstrate that if the project is not physically contiguous to an existing settlement, it will not result in greater costs to the municipality than it provides in additional tax revenues and other public benefits: a) Is the project tract physically contiguous to an existing settlement? [ ] Yes [ ] No. Existing settlement has been defined by the Environmental Board as an extant community center similar to the traditional Vermont center in that it is compact in size and contains a mix of uses, including commercial and industrial uses, and, importantly, a significant residential component. It is a place in which people may live and work and in which the uses largely are within walking distance of each other. b) If the project is not contiguous to an existing settlement, provide an analysis comparing the public benefits and costs of the project. If you are uncertain how to address this part of the criterion, contact the District Coordinator. _________________________________________________________________________ Criterion 9J) Public Utilities: Demonstrate that the project will not place an excessive or uneconomic demand on any necessary governmental or public utility facilities or services: a) Indicate whether an excessive or uneconomic demand will be placed on supportive governmental or public utility services, such as electric services, municipal water or sewer services, etc.). Attach copies of utility letters. _______________________________________________________________________ _______________________________________________________________________

Criterion 9K) Public Investments: Demonstrate that the project will not endanger any adjacent public investment: a) List any adjacent governmental or public utility facilities, services and lands, including highways, airports, waste disposal facilities, buildings, fire and police stations, universities, schools, hospitals, electric generation and transmission facilities, oil and gas pipelines, parks,
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hiking trails, forest and game lands, etc. _________________________________________________________________________

b) How will the project affect any such adjacent property? _________________________________________________________________________ Criterion 9L) Rural Growth Areas: To the extent that the project parcel or any area within the parcel is identified as a "rural growth area," indicate how the project has been clustered or otherwise designed to provide for reasonable population densities and rates of growth to economize on the cost of roads, utilities and land usage: a) Is the project located in a rural growth area? [ ] Yes [ ] No. Rural growth areas are lands which do not contain natural resources such as streams, wetlands, significant wildlife habitats, primary agricultural soils, and earth resources. (Contact the District Coordinator if you need assistance in determining how to address this Criterion.) b) If the project is located in a rural growth area, indicate how the project has been clustered and designed to economize on the cost of roads, utilities and land usage. Coordinator. _________________________________________________________________________ Criterion 10) Local and Regional Plans: Demonstrate that the project conforms to the municipal plan and regional plan. a) Does the municipality have a duly adopted plan? If so, explain how the project conforms to this plan. _________________________________________________________________________ _________________________________________________________________________ b) Have local approvals/permits been obtained? [ ] Yes [ ] No. (Attach copies) c) Explain how the project conforms to the regional plan. _________________________________________________________________________ _________________________________________________________________________ d) Explain how the project conforms to a duly adopted capital program, if the town has one. _________________________________________________________________________

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ACT 250 MUNICIPAL IMPACT QUESTIONNAIRE This questionnaire is intended to help applicants gather evidence to submit under Criterion 7 Municipal Services. A letter or narrative from the Town Manager, Selectboard Chair or appropriate official may also serve as evidence. APPLICANT TO COMPLETE: Applicant Name:______________________________Municipality: ________________________ Title and Date of Site Plan Submitted:________________________________________________ TOWN MANAGER, DEPARTMENT HEADS, OR EQUIVALENT TO COMPLETE: a) Does the municipality have the capacity to provide the following services without unreasonable burdens for the above project: Fire Protection Police Protection Rescue Service Solid Waste Disposal Road Maintenance __Yes __No __Yes __No __Yes __No __Yes __No __Yes __No __ Mun. does not provide this service. __ Mun. does not provide this service. __ Mun. does not provide this service. __ Mun. does not provide this service. __ Mun. does not provide this service.

b) If "no", what are the deficiencies? _________________________________________________ ____________________________________________________________________________ c) If the service is unavailable from the municipality, who provides the service so that the town doesn't have to? _____________________________________________________________ ____________________________________________________________________________ d) Would the deficiencies occur without this project? __Yes or __No? If "no", what measures can the applicant take to alleviate the deficiencies? ____________________________________________________________________________ ____________________________________________________________________________ e) If the deficiencies are common to many projects, does this project create burdens which are disproportionate to the taxes and user fees to be paid to the municipality? __Yes or __No? If "yes", does the municipality recommend the imposition of an impact fee or other means to mitigate any unreasonable burdens? ____________________________________________________________________________ f) Are you available, after sufficient notice, to answer questions related to the above statements at an Act 250 hearing? __Yes or __No I certify that the above information is true and accurate to the best of my knowledge. _____________________________________________ Name _____________________________________________ Position _____________________________________________ Date ACT 250
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SCHOOL IMPACT QUESTIONNAIRE FOR RESIDENTIAL PROJECTS This questionnaire is intended to help applicants gather evidence to submit under Criterion 6 Educational Services. A letter or narrative from the Superintendent or appropriate school official may also serve as evidence. APPLICANT TO COMPLETE: Applicant Name: _________________________________________________________________ Municipality: ____________________________________________________________________ Number of Lots or Units: __________________________________________________________ Estimated Number of Students____ Source of estimate: ________________________________ SCHOOL SUPERINTENDENT OR EQUIVALENT TO COMPLETE: a) What schools under your supervision will provide educational services for families who will live in this project? Elementary school____________________________________________________________ Middle school________________________________________________________________ High school__________________________________________________________________ b) Do these schools have the capacity to accept the additional students listed above? (assume equal grade distribution) [ ] Yes or [ ] No c) If "no", what is the deficiency?____________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ d) What plans are in place to correct the problem, including any capital construction projects ? ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ e) Do you have other comments? ___________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ f) Are you available, after sufficient notice, to answer questions related to the above statements at an Act 250 hearing? [ ] Yes or [ ] No I certify the above information is true and accurate to the best of my knowledge. _____________________________________ Name _____________________________________ Position __________________________________ Date
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