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DPNR-BP Application — Form I Page 1 of 2 FOR OFFICE USE Date received: Date deemed complete: Reviewed by : DEPARTMENT OF PLANNING AND NATURAL RESOURCES DIVISION OF BUILDING PERMITS 45 MARS HILL, Frederiksted, St. Croix, VI 00840 Cyril E. King Airport, Charlotte Amalie, VI 00801 PHONE: (840) 773-1082, FAX: (340) 773-9310/ (840)774-3320, FAX (840) 714 9549 Earth Change Permit Application Form J-Gut Clearing/Brush Clearing Only Note to all applicants: A thirty day period shall apply to the review of an earth change plan by DPNR. The 30-day period shall begin with the date of reception indicated above. However, termination of the 30-day period shall not give inferred or automatic approval to the application (12 VI Rules and Regs. §532-12). SECTION A: PROJECT INFORMATION (Please Print) Owner(s) Name as listed on Deed: Submit Proof of Legal Interest: (Copy of Deed/Lease with Covenants & Restrictions, if applicable or Purchase Agreement/Land Contract) Physical Address: Mailing address of owner: Telephone #: (H) (W) (Cell) Plot No: Estate: Acreage: Parcel Identification Number: Submit a copy of property tax bill or tax clearance letter (contact Tax Assessor’s Office: 773-6459 (C’Sted), 772-3115 (F’Sted), 776-8505 (STT/STJ) for information.) Zoning: Name and telephone number of certified earthwork contractor. DPNR-BP Application ~— Form | Proposed action(s) — check those that apply: C1 Land clearing [] Gut Clearing SECTION B: REQUIRED SUBMITTALS M Site Plan 1) A brief earth change plan in written form detailing the proposed method, equipment, and purpose of land clearing. Please check those that apply: LJ Crops LJ Livestock L] Both 2) A USDA Soil Conservation Plan is required for land clearing for agricultural purposes. (Contact USDA office for information at 692-9662) 3) Show all easements on the site and within 50 feet of the property line. 4) PNR/PWD/OLG Drawing; Recorded Parcel Map and/or Registered Survey Map (Registered with the Cadastral Section and STAMPED CERTIFIED by the Cadastral Public Surveyor). (2 Copies) 5) On PNR/PWD/OLG Drawing, sketch and identify areas to be cleared and proposed Best Management Practices (BMPs) to be installed. SECTION C: Signature Block Application is hereby made for a permit to authorize the activities described herein. I agree to provide any additional information/data that may be necessary to provide reasonable assurance or evidence to show that the proposed project will comply with the applicable territorial water quality standards or other building permits standards both during construction and after the project is completed. I also agree to provide entry to the project site for the inspectors from building permits in order to make inspections regarding this application. To the best of my knowledge and belief, that such information provided herein is true, complete and accurate; I further certify that I possess the authority to undertake the proposed activities. Signature of Owner(s) Signatures of all individuals listed on deed is required: Date: Revised 6-11