SVNF.PDF

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VII: Self-Verification Notification Form

Complete all fields (write “none” if applicable) below. Send this form and the existing plans to the address below, fax to (978) 318-8303, or email to before work within Corps jurisdiction commences unless otherwise specified. The Corps will acknowledge receipt of this form in writing. Please call (978) 318-8338 with questions.

cenae-r@usace.army.mil

Regulatory Division U.S. Army Corps of Engineers New England District 696 Virginia Road Concord, MA 01742-2751

:eettimreP Address, City, State & Zip:

Phone(s) and Email:

Project Location (provide detailed description if necessary):

Address, City, State & Zip:

Latitude/Longitude Coordinates (if address doesn’t exist):

Waterway Name:

Contractor:

Address, City, State & Zip:

Phone(s) and Email:

Project Purpose:

Work Description:

Work will be done under the following activity(s) in Section III, Eligible Activities (check all that apply):

)egap txen no deunitnoc(

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Aggregate total wetland impact area*: temporary SF permanent SF Aggregate total waterway impact area*: temporary SF permanent SF (*leave blank if work involves structures only)

Does your project include any secondary impacts? (See General Condition 3.) Yes No If yes, describe here:

Proposed Work Dates: Start: Finish:

Your name/signature below, as permittee, confirms that your project a) meets the self-verification criteria and b) that you accept and agree to comply with the applicable terms and conditions in the General Permits for Massachusetts.

Permittee Printed Name:

Permittee Signature: Date:

February