ALTERNATIVE SIGNATURES FORM

ALTERNATIVE SIGNATURES FORM
ALTERNATIVE SIGNATURES FORM
(Use When an Applicant is Not the Property Owner. Both Applicant and Property Owner Must Sign this Form)
12A. STATE CERTIFICATION AND FEDERAL PRIVACY ACT STATEMENT:
Application is hereby made for a permit or permits to authorize the work described in this application. I hereby designate and authorize the
agent named on the Abbreviated Joint Federal / State Application to act on my behalf in the processing of this application and to furnish
any information that is requested. I certify that the information on the Abbreviated Joint Federal / State Application and on the attached
plans and specifications is true and accurate to the best of my knowledge and belief. I understand that any of the agencies involved in
authorizing the proposed works may request information in addition to that set forth herein as may be deemed appropriate in considering
this proposal. I grant permission to the agencies responsible for authorization of this work, or their duly authorized representative, to enter
the project site for inspection purposes during working hours. I will abide by the conditions of all permit(s) or license(s) if issued and will
not begin work without the appropriate authorization. I also certify that the proposed works are consistent with Maryland’s Coastal Zone
Management Plan.
Authorities: Rivers and Harbors Act, Section 10, 33 USC 403; Clean Water Act, Section 404, 33 USC 1344; Marine Protection, Research,
and Sanctuaries Act, Section 103, 33 USC 1413; Regulatory Programs of the Corps of Engineers; Final Rule 33 CFR 320-332. Principal
Purpose: Information provided on this JPA will be used in evaluating the application for a permit. Routine Uses: This information may be
shared with the Department of Justice and other federal, state, and local government agencies, and the public and may be made available as
part of a public notice. Submission of requested information is voluntary, however, if information is not provided the permit application
cannot be evaluated nor can a permit be issued. Original drawings or good reproducible copies in an 8 ½” by 11” format which show the
location and character of the proposed activity must be attached to this application.
An application that is not completed in full will be returned.
Applicant(s)
Applicant’s Name (printed/typed)
Applicant’s Signature
Date
Applicant’s Name (printed/typed)
Applicant’s Signature
Date
Applicant’s Name (printed/typed)
Applicant’s Signature
Date
Property Owner(s)
Property Owner’s Name
(printed/typed)
Property Owner’s Signature
Date
Property Owner’s Name
(printed/typed)
Property Owner’s Signature
Date
Property Owner’s Name
(printed/typed)
Property Owner’s Signature
Date
VERSION 2013.08
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