"General Application Form" - Rhode Island

General Application Form is a legal document that was released by the Rhode Island Department of Environmental Management - a government authority operating within Rhode Island.

Form Details:

  • Released on February 11, 2019;
  • The latest edition currently provided by the Rhode Island Department of Environmental Management;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Rhode Island Department of Environmental Management.

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RHODE ISLAND DEPARTMENT OF ENVIRONMENTAL MANAGEMENT
OFFICE OF WATER RESOURCES \ FRESHWATER WETLANDS PROGRAM
235 Promenade Street, Providence, RI 02908
Telephone: 401-222-6820, Rhode Island Relay 711
AGENCY USE ONLY
GENERAL APPLICATION FORM
Application No:
Please type or print
PART A
Purpose of Application (see 250-RICR-150-15-1)
Request to Determine Presence of Wetlands only (250-RICR-150-15-1.8(B))
Application Received:
Request to Verify Delineated Edge of Wetlands (250-RICR-150-15-1.8(C))
Request for Preliminary Determination (250-RICR-150-15-1.9)
Application to Alter a Freshwater Wetland (250-RICR-150-15-1.10)
Application for Permit Renewal (250-RICR-150-15-1.11(B)) Complete Only Parts B, D & H
Application for Permit Modification (250-RICR-150-15-1.11(C))
Application for Permit Transfer (250-RICR-150-15-1.11(D)) Complete Only Parts B, E & H
Change in Owner during review (250-RICR-150-15-1.7(A)(2)(e)) Complete Only Parts B, F & H
PART B
Applicant Information:
Applicant’s Name (see 250-RICR-150-15-1.7(A)(2)):
______
Note: The applicant must be the owner of the property or easement which is the subject of this application or must be the government
agency or entity with power of condemnation over such property or easement.
Applicant’s Mailing Address:
Street/Road
P.O. Box
City/Town
State
Zip Code
Telephone No.
Applicant’s Email Address: (print legibly):
Property Location subject to this Application:
City/Town
Street Abutting Site
Street address number (if applicable)
Nearest street intersection and its distance and direction from site
Nearest utility pole number(s):
Direction to site from abutting street: N
S
E
W
Tax Assessor's Plat(s) and Lot No(s):
Recorded Plat(s) and Lot No(s) (if Assessor’s are not available):
PART C
General Information:
Any previous application for this site? Yes
No
Provide Application No(s)
Any previous enforcement action for this site? Yes
No
Provide File No(s)
Amount of wetland area to be altered, if any:
Palustrine wetland:
square feet
Riverbank or perimeter wetland:
square feet
Watercourse:
linear feet
Check here if any floodplain alteration is proposed.
• Fee category per
250-RICR-150-15-1.7(A)(11)
____________________Check No.
(
)
ex. 1.7(A)(11)(d)(6) 2-lots sub. Pre-Det. $900
Check here if the project has a Certificate of Critical Economic Concern (CEC) and attach copy of certification
.
PART D
For Application for Permit Renewal (if applicable):
Name of Original or Subsequent Permittee:
Application/Permit No.
Permit Expiration Date:
Number of previous renewals issued (if applicable):
Applicant’s Statement: I hereby state that I am requesting renewal of the original or subsequently modified permitted project under
Application/Permit No.
. I fully understand the permit limitations and will comply with any and all
conditions of the permit.
Applicant's name: (print)
(signature)
Check here if actual site work has commenced on the project for which renewal is requested.
fwwgenapp 02/11/19
www.dem.ri.gov
Page 1 of 2
RHODE ISLAND DEPARTMENT OF ENVIRONMENTAL MANAGEMENT
OFFICE OF WATER RESOURCES \ FRESHWATER WETLANDS PROGRAM
235 Promenade Street, Providence, RI 02908
Telephone: 401-222-6820, Rhode Island Relay 711
AGENCY USE ONLY
GENERAL APPLICATION FORM
Application No:
Please type or print
PART A
Purpose of Application (see 250-RICR-150-15-1)
Request to Determine Presence of Wetlands only (250-RICR-150-15-1.8(B))
Application Received:
Request to Verify Delineated Edge of Wetlands (250-RICR-150-15-1.8(C))
Request for Preliminary Determination (250-RICR-150-15-1.9)
Application to Alter a Freshwater Wetland (250-RICR-150-15-1.10)
Application for Permit Renewal (250-RICR-150-15-1.11(B)) Complete Only Parts B, D & H
Application for Permit Modification (250-RICR-150-15-1.11(C))
Application for Permit Transfer (250-RICR-150-15-1.11(D)) Complete Only Parts B, E & H
Change in Owner during review (250-RICR-150-15-1.7(A)(2)(e)) Complete Only Parts B, F & H
PART B
Applicant Information:
Applicant’s Name (see 250-RICR-150-15-1.7(A)(2)):
______
Note: The applicant must be the owner of the property or easement which is the subject of this application or must be the government
agency or entity with power of condemnation over such property or easement.
Applicant’s Mailing Address:
Street/Road
P.O. Box
City/Town
State
Zip Code
Telephone No.
Applicant’s Email Address: (print legibly):
Property Location subject to this Application:
City/Town
Street Abutting Site
Street address number (if applicable)
Nearest street intersection and its distance and direction from site
Nearest utility pole number(s):
Direction to site from abutting street: N
S
E
W
Tax Assessor's Plat(s) and Lot No(s):
Recorded Plat(s) and Lot No(s) (if Assessor’s are not available):
PART C
General Information:
Any previous application for this site? Yes
No
Provide Application No(s)
Any previous enforcement action for this site? Yes
No
Provide File No(s)
Amount of wetland area to be altered, if any:
Palustrine wetland:
square feet
Riverbank or perimeter wetland:
square feet
Watercourse:
linear feet
Check here if any floodplain alteration is proposed.
• Fee category per
250-RICR-150-15-1.7(A)(11)
____________________Check No.
(
)
ex. 1.7(A)(11)(d)(6) 2-lots sub. Pre-Det. $900
Check here if the project has a Certificate of Critical Economic Concern (CEC) and attach copy of certification
.
PART D
For Application for Permit Renewal (if applicable):
Name of Original or Subsequent Permittee:
Application/Permit No.
Permit Expiration Date:
Number of previous renewals issued (if applicable):
Applicant’s Statement: I hereby state that I am requesting renewal of the original or subsequently modified permitted project under
Application/Permit No.
. I fully understand the permit limitations and will comply with any and all
conditions of the permit.
Applicant's name: (print)
(signature)
Check here if actual site work has commenced on the project for which renewal is requested.
fwwgenapp 02/11/19
www.dem.ri.gov
Page 1 of 2
PART E
For Application for Permit Transfer (if applicable):
Original Permittee’s Name:
Application/Permit No.:
Permit Expiration Date:
Note: A certified copy of the deed of transfer must be enclosed with application.
Applicant’s Statement: I hereby certify that I have reviewed the permit letter issued under Application/Permit No.
and hereby agree to comply with all conditions of the permit, including any time limitations imposed.
Applicant's Name (print):
(signature):
Date:
PART F
For Change in Owner During Application Processing (if applicable):
Original Applicant’s Name:
Application No.
Note: A certified copy of the deed of transfer must be enclosed for Applications to Alter only.
PART G
Certification of Professional(s) (if applicable):
Note: Any professional (e.g. engineer, biologist, landscape architect, etc.) who participated in the submission
and/or preparation of this Application and supporting documentation must sign below.
I hereby certify that I have been authorized by the applicant to prepare documentation to be submitted in support of this Application;
that such documentation is in accordance with the
Rules and Regulations Governing the Administration and Enforcement of the
Freshwater Wetlands Act
(250-RICR-150-15-1); and that such documentation is true, accurate and complete to the best of my
knowledge.
Professional’s Name (print):
Title:
Email (print legibly):
d/b/a:
Address:
Professional’s Signature:
Date:
Check this box if the above named is the project manager or project lead for the applicant.
I’ve completed and attached the
Site Work
Affidavit.
If more than one professional:
Professional’s Name (print):
Title:
Email (print legibly):
d/b/a:
Address:
Professional’s Signature:
Date:
I’ve completed and attached the
Site Work
Affidavit.
Professional’s Name (print):
Title:
Email (print legibly):
d/b/a:
Address:
Professional’s Signature:
Date:
I’ve completed and attached the
Site Work
Affidavit.
PART H
Certification/Authorization of Applicant:
I hereby certify that I have requested and authorized the investigation, compilation, and submission of all the information, in whatever
form, contained in this Application; that I have personally examined and am familiar with the information submitted herein; and that
such information is true, accurate and complete to the best of my knowledge. I hereby authorize RIDEM personnel access to the
property for purposes of observing conditions pertinent to this application and assessing compliance with any permit or determination
resulting from this application, including any sampling, monitoring or surveying that may be deemed appropriate, consistent with
the RIDEM Administrative Inspection Guidelines. (See DEM website - Office of Compliance and Inspection for copy).
Note any special concerns for access here:
Applicant’s Signature:
Title (if applicable):
See
250-RICR-150-15-1.7(A)(2)
regarding Signatures
Print Name Signed Above:
Date:
fwwgenapp 02/11/19
www.dem.ri.gov
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