Basic Form LR Land Use Review Application Department of City Planning 120 Broadway, 31st Floor, New York, NY 1027 1 City Planning will assign and stamp reference numbers here APPLICATION NUMBER APPLICATION NUMBER APPLICATION NUMBER APPLICATION NUMBER 1. APPLICANT AND APPLICANT=S REPRESENTATIVES APPLICANT (COMPANY/AGENCY OR OTHER ORGANIZATION) * APPLICANT'S PRIMARY REPRESENTATIVE STREET ADDRESS REPRESENTATIVE=S COMPANY/AGENCY OR OTHER ORGANIZATION CITY STATE ZIP STREET ADDRESS AREA CODE TELEPHONE # FAX# CITY STATE ZIP * List additional applicants below: CO-APPLICANT (COMPANY/AGENCY OR OTHER ORGANIZATION ) AREA CODE TELEPHONE # FAX# CO-APPLICANT (COMPANY/AGENCY OR OTHER ORGANIZATION ) ADDITIONAL APPLICANT REPRESENTATIVE: NAME AND PROFESSIONAL AFFILIATION (ATTORNEY/ARCHITECT/ENGINEER ETC.) TELEPHONE # FAX # 2. SITE DATA (If the site contains more than one property complete the "LR Item 2. Site Data Attachment Sheet.") STREET ADDRESS PROJECT NAME (IF ANY) DESCRIPTION OF PROPERTY BY BOUNDING STREETS OR CROSS STREETS EXISTING ZONING DISTRICT (INCLUDING SPECIAL ZONING DISTRICT DESIGNATION, IF ANY) ZONING SECTIONAL MAP NO(S). TAX BLOCK AND LOT NUMBER BOROUGH COMM. DIST. URBAN RENEWAL AREA, HISTORIC DISTRICT OR OTHER DESIGNATED AREA (IF ANY) IS SITE A NEW YORK CITY OR OTHER LANDMARK? NO YES IF YES, IDENTIFY 3. DESCRIPTION OF PROPOSAL (If the entire project description does not fit in this space, enter "see attached description" below and submit description on a separate sheet, identified as "LR item 3. Description of Proposal") 4. ACTIONS REQUESTED AND FEES (Check appropriate action(s) and attach supplemental form) * No supplemental form required CHANGE IN CITY MAP..................MM ZONING MAP AMENDMENT...........ZM ZONING TEXT AMENDMENT......... ZR ZONING SPECIAL PERMIT................ZS ZONING AUTHORIZATION.............ZA ZONING CERTIFICATION...............ZC PUBLIC FACILITY, SEL../ACQ..........PF DISPOSITION OF REAL PROP........PP URBAN DEVELOP=T ACTION.........HA URBAN RENEWAL PROJECT...........* HOUSING PLAN & PROJECT............* FRANCHISE...................................* REVOCABLE CONSENT..................* CONCESSION................................* LANDFILL......................................* OTHER (Describe) $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ MODIFICATION $ FOLLOW-UP APPLICATION NO. RENEWAL APPLICATION NO. OTHER SPECIFY TOTAL FEE (For all actions) $ $ $ $ Make Check or Money Order payable to Department of City Planning. If fee exemption is claimed check box below and explain Has pre-application meeting been held? If yes NO YES $ DCP Office/Representative Date of meeting lr 0505 pdf American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 2 Basic Form LR ­ continued 5. ENVIRONMENTAL REVIEW CITY ENVIRONMENTAL QUALITY REVIEW (CEQR) (Discuss with CEQR lead agency before completing) LEAD AGENCY TYPE OF CEQR ACTION: TYPE II TYPE I UNLISTED Type II category: Date determination was made: Yes No CEQR NUMBER } Has EAS been filed? If yes, Date EAS filed: Has CEQR determination been made? If yes, what was determination? Yes Negative Declaration CND ...................... No Positive Declaration If Positive Declaration, has PDEIS been filed? Has Notice of Completion (NOC) for DEIS been issued? If PDEIS has not been filed, has final scope been issued? } Date determination made: (Attach Copy) If yes, attach copy. If yes, date issued: 6. COASTAL ZONE MANAGEMENT IS SITE IN STATE DESIGNATED COASTAL ZONE MANAGEMENT (CZM)? AREA? No Yes 7. RELATED ACTIONS BY CITY PLANNING LIST ALL CURRENT OR PRIOR CITY PLANNING COMMISSION ACTIONS RELATED TO SITE: APPLICATION NO. DESCRIPTION/ DISPOSITION/STATUS CAL. NO. DATE 8. RELATED ACTIONS BY OTHER AGENCIES LIST ALL OTHER CURRENT OR PRIOR CITY, STATE OR FEDERAL ACTIONS RELATED TO APPLICATION: REFERENCE NO. DESCRIPTION/ DISPOSITION/STATUS CAL. NO. DATE 9. FUTURE ACTIONS REQUIRED LIST ALL FUTURE CITY, STATE OR FEDERAL ACTIONS REQUIRED TO IMPLEMENT THE PROPOSED ACTION: 10. APPLICANT (Attach authorizing resolution(s), if applicable) NAME AND TITLE OF APPLICANT OR AUTHORIZED REPRESENTATIVE SIGNATURE OF APPLICANT DATE APPLICANT'S COMPANY/AGENCY OR OTHER ORGANIZATION (IF ANY) 11. CO-APPLICANTS NAME AND TITLE OF CO-APPLICANT OR AUTHORIZED REPRESENTATIVE SIGNATURE OF CO-APPLICANT DATE (Attach authorizing resolution(s), if applicable) CO-APPLICANT=S COMPANY/AGENCY OR OTHER ORGANIZATION STREET ADDRESS CITY STATE ZIP TEL.NO. FAX NAME AND TITLE OF CO-APPLICANT OR AUTHORIZED REPRESENTATIVE SIGNATURE OF CO-APPLICANT DATE CO-APPLICANT=S COMPANY/AGENCY OR OTHER ORGANIZATION STREET ADDRESS CITY STATE ZIP TEL.NO. FAX ADMINISTRATIVE CODE NOTICE ANY PERSON WHO SHALL KNOWINGLY MAKE A FALSE REPRESENTATION ON OR WHO SHALL KNOWINGLY FALSIFY OR CAUSE TO BE FALSIFIED ANY FORM, MAP, REPORT OR OTHER DOCUMENT SUBMITTED IN CONNECTION WITH THIS APPLICATION SHALL BE GUILTY OF AN OFFENSE PUNISHABLE BY FINE OR IMPRISONMENT OR BOTH, PURSUANT TO SECTION 10-154 OF THE CITY OF NEW YORK ADMINISTRATIVE CODE. THIS APPLICATION WILL BE DEEMED PRELIMINARY UNTIL IT IS CERTIFIED AS COMPLETE BY THE DEPARTMENT OF CITY PLANNING OR THE CITY PLANNING COMMISSION. ADDITIONAL INFORMATION MAY BE REQUESTED OF THE APPLICANT BY THE DEPARTMENT OF CITY PLANNING. lr 0505 pdf American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2