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MINOR WATER United States Virgin Islands Department of Planning and Natural Resources Development Permit Application 1.00 NAME AND ADDRESS OF APPLICANT 2.00 LOCATION OF PROJECT 2.01 Location and Agency Review Map 2.02 A copy of the Vicinity Map 3.00 ABSTRACT 4.00 STATEMENT OF OBJECTIVES SOUG HT BY THE PROPOSED PROJECT 5.00 DESCRIPTION OF PROJECT 5.01 SUMMARY OF PROPOSED ACTIVITY (To be provided on drawings) a. Discuss purpose of project b. Discuss the presence and location of any critical area(s) and possible trouble spots c. Discuss proposed method of construction d. Discuss provisions to limit site disturbance e. Discuss sedimentation control methods to be implemented f. Show schedule for construction activities & implementation of sediment control measures. g. Discuss the maintenance of sediment and siltation control measures 6.00 OTHER REQUIRED SUBMITTALS a. Application Letter (Form L&WD-1) b. Joint Application, U.S. Army Corps of Engineers/Virgin Islands Department of Planning and Natural Resources c. Proof of Legal Interest (Form L&WD-5) d. Income tax clearance letter (Form L&WD-6) e. Corporate and Association Application Form – If a corporation is the applicant, developer or owner of the project (Form L&WD-7) f. Certificate of Corporate Good Standing or Equivalent (For corporate applicants, associations, developers or owners) g. Copy of Deed/Lease/Purchase Agreement/Easement Rights. h. Application Fees i. List all property owners within a 150’ radius of the property boundaries. Include current mailing addresses as exist at the tax assessor’s office. j. Qualifications & background of designers, engineers & other professionals involved with the project. k. A cost estimate (materials and labor) must be submitted. l. Revenue projection – provide the total gross revenue that can be generated from the proposed project m. Environmental Assessment Report for Minor Projects in Coastal Waters. DEPARTMENT OF PLANNING AND NATURAL RESOURCES DIVISION COASTAL ZONE MANAGEMENT ENVIRONMENTAL ASSESSMENT REPORT FOR MINOR PROJECTS IN COASTAL WATERS Instructions for Completing this Report: Applicant must complete this form. Use back of page and/or attach additional sheets if more spaces are needed to complete any response - be sure to give the appropriate question number. If all information is not accurate and complete, the application will be rejected until such deficiencies are corrected. Section I. Applicant 1. Name, mailing address, email address and telephone number of Applicant. 2. Name, address, email address and telephone number of owner of upland property and of developer (if different from Applicant). Section II. Project Objectives and Description In this section give a brief description of the proposed development, including all structures on submerged lands, coastal waters or shorelines. The relationship of the development to applicable items below should be explained fully. Attach additional sheets if necessary. 3. Briefly describe what the project is intended to achieve (e.g. private pier for sailboats, etc.) 4. Will the development extend into or adjoin any beach or shoreline area? Explain. 5. Will the development maintain, enhance, or conflict with public access to the shoreline and along the coast? Explain. 6. Describe the construction methods to be used. 7. Describe procedures to be used in controlling environmental impacts. 8. Describe reasonable alternatives to the project, or to its location, which could feasibly attain the basic objectives, and why they were rejected in favor of the ultimate choice. Section III. Description of the Existing Environment Without the Project (Information supplied must be current: if obtained from other studies, give name, year and authorship of publication.) 9. Give a qualitative description of the bottom sediments in the immediate vicinity of the project. State color, odor, and use the following terms to describe grain size: boulders, cobblestones, gravel, coarse sand, muddy sand, mud, beachrock coral rock. 10. Check the boxes which best describe the types of coastal submarine habitats existing within the immediate project area, and within 1/4 mile (1,320 ft.) from the project boundaries:  corals, including soft corals  salt ponds  seagrass or algal beds  rocky shore  hard, rocky bottom  sand beach  sand bottom  cobble beach  muddy bottom  developed or urbanized waterfront  mangroves  other (describe) Section IV. Environmental Effects 11. List any anticipated adverse environmental effects resulting from implementation of this project and any measures that will be taken to minimize these. Section V. Preparation of EAR and Person(s) Consulted 12. Person(s), firm or agency preparing the EAR, by contract or other authorization: Name (Print) (Signature) Date Address Zip Email Address Telephone Number 13. Person(s) or agencies consulted: GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES DEPARTMENTOF PLANNING AND NATURAL RESOURCES DEVELOPMENT PERMIT APPLICATION FORM L&WD-1* JOINT PERMIT APPLICATION LETTER COMMISSIONER DEPARTMENT OF PLANNING AND NATURAL RESOURCES 8100 LINDBERG BAY, STE #61 CYRIL E. KING AIRPORT TERMINAL, SECOND FLOOR ST. THOMAS, US VIRGIN ISLANDS 00802 Dear Commissioner: The undersigned wishes to make application to the Virgin Islands Government and the Secretary to the Army for a permit to: It is understood that approval of this application is required pursuant to Act No. 4248 of the Virgin Islands Code, and I hereby certify that the proposed activity complies with the enforceable policies of the VI CZM Act and that the development will be conducted in a manner consistent with the VI Coastal Zone Management Program. Included in this application is the Department of the Army permit application form (ENG 4345). It is further requested that this letter and application be forwarded to the US Army Corps of Engineers, Antilles Regulatory Section, for consideration. Signature of Applicant (Sign) (Print) Date Official Title, if a Corporation *Not required if the application is for the continued use and occupancy of an existing structure, and no development activities will be taking place. SIGN Revised August 2016 GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES DEPARTMENT OF PLANNING AND NATURAL RESOURCES DEVELOPMENT PERMIT APPLICATION FORM L&WD-2 PERMIT APPLICATION Date Received: _______________ Date Declared Complete: Permit Application No.: Application is hereby made for an  Earth Change  Coastal Zone Permit 1. Name, mailing address, email address and telephone number of Applicant (person/entity with legal interest in the property, to which permit will be issued) 2. Name, mailing address, email address and telephone number of Owner of property and Agent (if any) Owner(s) of Property Agent 3. Location of activity. Plot No.: PIN No.: - - - Estate: Island: 4a. Zoning District: 4b. State type of Land Uses as specified in the VI Zoning Law, which are applied for (e.g., restaurant, hotel, single-family dwelling, etc.) 5. Name, mailing address, email and telephone number of project designer. 6. Summary of proposed activity. Include all incidental improvements such as utilities, roads, etc. (Use additional sheets if necessary). Revised August 2016 FORM L&WD-2/PERMIT APPLICATION CONT'D 7. Date activity is proposed to start ; be completed 8. Classification of minor or major permit. Check one:  Minor Permit Application  Major Permit Application State below which criterion applies in making above check. 9. 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 air and water quality standards, or other environmental protection standards, both during construction and after the project is completed. I also agree to provide entry to the project site for inspectors from the Department of Planning and Natural Resources, or other environmental protection agencies, for the purpose of making inspection regarding this application. To the best of my knowledge and belief, the information provided herein is true, complete, and accurate. I further certify that I possess the authority to undertake the proposed activities. Signature of Applicant or Agent (if not owner) Sign Print Date Signature of Owner(s) of the property (Required) Sign Print Date Sign Print Date FOR DEPARTMENT USE ONLY Inspector Record Date Inspected:  Application Approved  Application Disapproved Inspector's Remarks: Inspector Date Commissioner, Planning & Natural Resources Date SIGN SIGN SIGN Revised August 2016 GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES DEPARTMENT OF PLANNING AND NATURAL RESOURCES DEVELOPMENT PERMIT APPLICATION FORM L&WD-5 PROOF OF LEGAL INTEREST AFFIDAVIT I, being duly sworn depose and say that: Applicant(s)* (or John Doe of Entity Applicant) 1. ____________________________________am/are/is the (check one below) (I/We or Entity/Applicant)  Record title owner (fee simple)  Lessee  Other (specify) Of the real property described as Parcel No(s) Estate Quarter Island *This Form seeks to establish the relationship of the Applicant to the property where activity will occur. *Applicant(s) is required to provide documentation for legal interest stated above (e.g. deed, lease, etc.) *If applicant is a Trust: please provide trust declaration appointing Trustee” *Property tax clearance letter from the Lieutenant Governor’s Office. 2. I have the irrevocable approvals, permission, or power of attorney from all other persons with a legal interest in the property to undertake the work proposed in the permit application as more fully set forth in the exhibit (s) attached hereto: Signature Date Signature Date Print Print The foregoing instrument was acknowledged before me this day of 20 by at county (Name or Name/Title of Entity) of . Notary Public My Commission expires Revised August 2016 GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES -0- VIRGIN ISLANDS BUREAU OF INTERNAL REVENUE (DPNR FORM L&WD-6) APPLICATION FOR TAX FILING AND PAYMENT STATUS REPORT** Date: The applicant identified below hereby requests a letter certifying his or her tax filing and payment status for the purpose of receiving a Coastal Zone Management Permit from the Virgin Islands Department of Planning and Natural Resources pursuant to Act 5270, amending Sections 910 (a)(2) and 911 (d)(2) of the Coastal Zone Management Act (Title 12, Chapter 21, Virgin Islands Code). The applicant authorizes the Bureau of Internal Revenue to disclose any taxpayer information necessary to process this application to the Virgin Islands Department of Planning and Natural Resources, who may make such further disclosures as are necessary to carry out the requirements of the Coastal Zone Management Act, as amended. Name: Business Name: EIN/TIN: SSN: Please Indicate: Type of Business: *Corporation *Partnership Please check forms that you use:  Individual 1120, 1065, l 040, 941VI,  Other 722VI, 720B, 720VI, other (list) Date Business Started: Person Representing Applicant: Position: Signature: Mailing Address: Date: Telephone Number: Reply to: 6115 Estate Smith Bay, suite 225, St. Thomas VI 00802 – 340-715-1040(phone), 340-774-2672(fax) or 4008 Estate Diamond, St. Croix VI 00820 – 340-773-1040(phone), 340-773-1006(fax) * Partnership and/or Corporations must list partners/ corporate officers, social security numbers and addresses on a separate sheet and attach it to this application. THIS FORM IS TO BE SUBMITTED TO VIBIR UPON COMPLETION SIGN GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES DEPARTMENT OF PLANNING AND NATURAL RESOURCES DEVELOPMENT PERMIT APPLICATION PUBLIC NOTICE (SUPPLEMENT TO FORM L&WD-6) Pursuant to Act 5270, as approved by the Governor of the Virgin Islands on July 30, 1987, amending Section 910 (a) (2) and 911 (d) (2) of the Coastal Zone Management Act (Title 12, VI Code, Chapter 21), all applicants for Coastal Zone Management permits are required to present "certification from Bureau of Internal Revenue and Department of Finance" indicating "that the applicant has filed and paid all taxes, penalties and interest, and from the Office of the Lieutenant Governor that the applicants has filled its required annual report or has satisfactorily made agreement to pay the taxes or fill the required reports "12 VIC 910 (a) (2) (C), and " (2) A coastal zone permit that includes an occupancy or development lease shall only be granted for a particular parcel of filled land for a lease period of not more than 20 years; provided that nothing in this subsection shall prohibit a lessee or permittee from executing a new lease at the end of the 20 year period. Any lease executed at the end of the lease period shall meet the requirements of this Chapter and shall be approved by the Governor and ratified by the Legislature, or in the event the Legislature is not in session, by the Committee on Planning and Environmental Protection. For applicants not required by law to submit an annual report or to satisfactorily make an agreement to pay taxes or file the required reports, a letter from the Bureau of Internal Revenue, and/or the Department of Finance, and/or the Lieutenant Governor's office so indicating will be required to continue further processing of the application. Accordingly, all Coastal Zone Management permit applications (both minor and major), which are not accompanied by the certificates, as required by Act 5270, or written notification from said agencies indicating waiver or exemption of these requirements will not be accepted by the permitting office. It is the responsibility of each applicant to demonstrate compliance with the provisions of this Act. GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES DEPARTMENT OF PLANNING AND NATURAL RESOURCES DEVELOPMENT PERMIT APPLICATION FORM L&WD-7 CORPORATION/ASSOCIATION APPLICATION (To be used when a corporation or association is making a Permit Application in Tier l) (Corporation or Association Name) By: ___________________________ (Signature) Title/Position (Print) President or Vice-President or equivalent Print WITNESS: ATTEST: Secretary (or equivalent) Signature Secretary (or equivalent) Print Seal On this day of , 20 . before me the undersigned officer, personally appeared , who acknowledges himself to be the of ; that he executed the foregoing instrument in the capacity above and has the authority to execute this application on behalf of the company. IN WITNESS WHEREOF, I have hereunto set my hand and official seal the day and year above written. ____________________________________________ Include Supporting Documents: 1. Compliance with Act No. 5270 by providing: (a) Tax clearance letter from the Bureau of Internal Revenue (b) Property tax clearance letter from the Lieutenant Governor’s Office. (c) Corporations and Associations: Certificate of Good Standing or equivalent, organizational documents & Amendments (Articles, Bylaws, Operating Agreement, Declarations) (d) Corporate Resolution (or equivalent) authorizing action on behalf of the company. GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES DEPARTMENT OF PLANNING AND NATURAL RESOURCES DEVELOPMENT PERMIT APPLICATION FEE SCHEDULE (TIER 1 ONLY) As provided in Title 1 2, Chapter 21, Section 910(e)(4) VIC and set forth in Tit le 12 V.I. Ru les and Regulations Subsection 910, effective September 18, 1992, a non-refundable administrative processing fee will be required to be filed with the applications for all Coastal Zone Permits in accordance with the following fee schedule: (A) Minor Coastal Zone Permit Application (i) For estimated construction cost of $10,000 or less .................................... $50.00 (i i ) For estimated construction cost greater than $10,000 but less than $25,000 .............................................. $125.00 (iii) For estimated construction cost of $25,000 or greater ............................. $200.00 (B) Major Coastal Zone Permit Application (i) For estimated construction cost of $250,000 or less ................................ $500.00 (ii) For estimated construction cost of $250,000 but less than $500,000 ............................................ $750.00 (iii) For estimated construction cost of $500,000 or greater ........................ $1 ,000.00 Whenever the Commissioner finds that the processing of a Major Coastal Zone Permit Application requires significant administrative expenditures in excess of those typically required, additional reasonable fees may be assessed to cover, for instance, the hiring of consultants when specialized expertise is needed that is not available in the Department. SIGN SIGN SIGN