Joint Application Form for Permits Affecting Streams, Waterways, Wetlands, Coastal Areas, and Water Sources

JOINT APPLICATION FORM

For Permits for activities activities affecting streams, waterways, waterbodies, wetlands, coastal areas, sources of water, and endangered and threatened species.

You must separately apply for and obtain Permits from each involved agency before starting work. Please read all instructions.

1. Applications To:

>NYS Department of Environmental Conservation Check here to confirm you sent this form to NYSDEC. Check all permits that apply: Dams and ImpoundTidal Wetlands Water Withdrawal Stream Disturbance ment Structures Wild, Scenic and Long Island Well Excavation and Fill in 401 Water Quality Recreational Rivers L] Navigable Waters L] Certification* — = Incidental Take of Coastal Erosion Endangered / L] Docks, Moorings or Freshwater Wetlands Management Threatened Species Platforms

>US Army Corps of Engineers

Army Corps of Engineers Check here to confirm you sent this form to USACE. Check all permits that apply: Section 404 Clean Water Act L] Section 10 Rivers and Harbors Act Is the project Federally funded? a Yes v No If yes, name of Federal Agency: General Permit Type(s), if known: CS Preconstruction Notification: | Yes a No

>NYS Office of General Services Check here to confirm you sent this form to NYSOGS. Check all permits that apply: State Owned Lands Under Water Utility Easement (pipelines, conduits, cables, etc.) Docks, Moorings or Platforms

>NYS Department of StateNYS Department of StateS Department of State Department of State

>NYS Department of StateNYS Department of StateS Department of State Department of State Check here to confirm you sent this form to NYSDOS. Check if this applies: Coastal Consistency Concurrence

|2. Name of Applicant|2. Name of Applicant|||||J|Taxpayer ID(ifapplicantisNOT J|Taxpayer ID(ifapplicantisNOT J|Taxpayer ID(ifapplicantisNOT J|Taxpayer ID(ifapplicantisNOT J|Tan individual) J|Tan individual) J| |---|---|---|---|---|---|---|---|---|---|---|---|---| |||||||J|J|J|J|J|J|J| |MailingAddress||||||J|Post Office / City J||J|J|StateZi J|Zip J| |||||||||||||| |||||||||||||| |Telephone||Email||||||||||| |Applicant Must be (check all that apply):||||Owner|||L]|Operator|LJ|Lessee||| |||||||||||||| |3. Name of Property Owner(if different than Applicant)||||||||||||| |||||||||||||| |MailingAddress|||||||Post Office / City||||StateZi|Zip| |||||||||||||| |Telephone||Email|||||||||||

For Agency Use Only Agency Application Number:

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4. Name of Contact / Agent

|4. Nameamemee of Contactf ContactContactntacttact / Agent Agentgentntt Tracey Ledder, Delaware Engineering DPC|4. Nameamemee of Contactf ContactContactntacttact / Agent Agentgentntt Tracey Ledder, Delaware Engineering DPC||||||||| |---|---|---|---|---|---|---|---|---|---| |MailingAddress|||||Post Office / City|||StateZi|Zip| |Delaware Engineering DPC 28 Madison Avenue Extension|||||Albany||||12203| ||||||||||| |Telephone|518-452-1290|Email|tledder@delawareengineering.com||||||| ||||||||||| ||||||||||| |5. Project / Facility Name|||||||Property Tax Map Section / Block / Lot Number:||| ||||||||||| |Project Street Address, if applicable|||||Post Office / City|||State|Zip| |US Route 9/Village ofRed Hook|||||Red Hook|||NY|42571| |Provide directions and distances to roads, intersections, bridges and bodies of water|||||||Provide directions and distances to roads, intersections, bridges and bodies of water|||

6. Project Description: Provide the following information about your project. Continue each response and provide any additional information on other pages. Attach plans on separate pages.

• a. Purpose of the proposed project:

b. Description of current site conditions:

c. Proposed site changes:

• d. Type of structures and fill materials to be installed, and quantity of materials to be used (e.g., square feet of coverage, cubic yards of fill material, structures below ordinary/mean high water, etc.):

• e. Area of excavation or dredging, volume of material to be removed, location of dredged material placement:

• f. Is tree cutting or clearing proposed? Yes If Yes, explain below. No Timing of the proposed cutting or clearing (month/year): Number of trees to be cut: Acreage of trees to be cleared:

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7. Signatures.

Applicant and Owner (If different) must sign the application.

attestation form

landowner , if

Append additional pages of this Signature section if there are multiple Applicants, Owners or Contact/Agents.

I hereby affirm that information provided on this form and all attachments submitted herewith is true to the best of my knowledge and belief.

Permission to Inspect - I hereby consent to Agency inspection of the project site and adjacent property areas. Agency staff may enter the property without notice between 7:00 am and 7:00 pm, Monday - Friday. Inspection may occur without the owner, applicant or agent present. If the property is posted with "keep out" signs or fenced with an unlocked gate, Agency staff may still enter the property. Agency staff may take measurements, analyze site physical characteristics, take soil and vegetation samples, sketch and photograph the site. I understand that failure to give this consent may result in denial of the permit(s) sought by this application.

False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the NYS Penal Law. Further, the applicant accepts full responsibility for all damage, direct or indirect, of whatever nature, and by whomever suffered, arising out of the project described herein and agrees to indemnify and save harmless the State from suits, actions, damages and costs of every name and description resulting from said project. In addition, Federal Law, 18 U.S.C., Section 1001 provides for a fine of not more than $10,000 or imprisonment for not more than 5 years, or both where an applicant knowingly and willingly falsifies, conceals, or covers up a material fact; or knowingly makes or uses a false, fictitious or fraudulent statement.

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Signature of Applicant Date Applicant Must be (check all that apply): Owner Operator Lessee L| LI Printed Name Title Karen Smythe Mayor, Village of Red Signature of Owner (if different than Applicant) Date Printed Name Title Signature of Contact / Agent Date “Feacey Zi [ob] Printed Name Title ----- End of picture text -----

For Agency Use Only DETERMINATION OF NO PERMIT REQUIRED

Agency Application Number (Agency Name) has determined that No Permit is required from this Agency for the project described in this application. Agency Representative: Printed Title Name Signature Date

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