Fillable Municipal General Permit Authorization Form printable pdf download

NYS Department of Environmental Conservation

MUNICIPAL GENERAL PERMIT (GP-5-12-001)

Authorization Form

Joe Martens

Commissioner

Municipality: _____________________________ Contact Name: ___________________________________

Phone Number: _______________________ Email _____________________Fax______________________

Exact Project Location: _____________________________________________________________________

Stream / Water body name or DEC Wetland ID: __________________________________________________

Project Description: ________________________________________________________________________

________________________________________________________________________________________

Project Start Date: __________________

Work during Trout prohibition period? (Cond. #8) __ YES __ NO

In-water equipment operation?

(Cond. #30) __ YES __ NO

Project End Date: ___________________ Will Project Require a TRP for use of State land? __ YES __ NO

Not Valid Until Signed By County or Municipality:

I have read and understand the GP-5-12-001 permit terms and conditions. I

hereby affirm that information provided on this Authorization Form (AF) form is true to the best of my knowledge and belief. False statements

made herein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the Penal Law. Further, the County or Municipality

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. I understand that, by submitting this AF, I am agreeing to comply with all the terms and conditions of the issued GP-5-12-001

for which this AF is being submitted.

Print Name and Title: ______________________________________________________________________

Signature: ________________________________________________ Date: __________________________

Not Valid Until: This form must be completed and submitted by email, Fax or US mail to the appropriate DEC

office at least three business days prior to start of project. The form section below will indicate approval or denial

of project-specific conditions, if applicable, and will be date-stamped by DEC and returned to sender. The

expiration date of this authorization shall be one calendar year from the date on the DEC stamp.

for projects located in Clinton, Essex, Hamilton,

for projects located in Fulton, Saratoga, Washington,

Franklin counties:

Warren counties:

NYSDEC

Division of Environmental Permits

PO Box 296, Route 86

232 Golf Course Road

Ray Brook, NY 12977-0296

Warrensburg, NY 12885

Phone: (518) 897-1234

Phone: (518) 623-1281

FAX: (518) 897-1394

FAX: (518) 623-3603

email: r5dep@gw.dec.state.ny.us

For DEC Use Only

DEC#: 5 -

Stream Disturbance (Bed and Banks)

NYTM-E:______________

Navigable Waters (Excavation and Fill)

NYTM-N:______________

Freshwater Wetlands

401 Water Quality Certification

Work during Trout prohibition period: Approved

Denied

In-water equipment operation:

Approved

Denied

Municipal General Permit Authorization Form

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