Fillable Inland Wetlands and Watercourses Agency (City of Bridgeport)

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Inland Wetlands and Watercourses Agency (City of Bridgeport)

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BROWSE CITY OF BRIDGEPORT (CT) FORMS

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Inland Wetlands and Watercourses Agency
City of Bridgeport
45 Lyon Terrace, Room 210
Bridgeport, CT 06604
Tel: (203) 576-7217 Fax: (203) 576-7213
Application for a Permit to Conduct Regulated Activities
1. Project Information:
a. Name of Applicant: _______________________________________________________
Applicant’s Interest in Property: Owner: ___ Lessee: ___ Agent: ___ Other: ___
Business Address: _______________________________________________________
Phone Number: _____________________ Fax Number: ________________________
b. Name of Property Owner (If Not Applicant): ____________________________________
Address: _______________________________________________________________
Phone Number: _________________________________________________________
2. Existing Conditions:
a. Project Title: ________________________ Total Site Acreage: __________________
Project Address: _________________________________________________________
Block No.: ______ Lot No.: ______ Present Use of Property: ____________________
b. Total Onsite Wetland Acreage: ______ Total Onsite Watercourse Length: __________
3. Proposed Conditions:
a. The proposed activity will affect (Please check where appropriate):
Wetland: _____ Watercourse/Open Water: _____ Setback: _____ Other: _____
b. Wetland Acreage Affected: ________ Watercourse Length Affected: _________
c. Description of the project in relationship to regulated areas for which authorization is
requested (include closest distance proposed activity is from regulated areas):
4. Notice Requirements:
a. A list of the names and mailing addresses of abutting property owners requiring
notification of this application as per the Inland Wetlands and Watercourses Regulations,
Section 7.5.h.
b. The applicant shall certify whether any portion of the property is located within five-
hundred (500) feet of the boundary of an adjoining municipality, Section 7.7.a and
Section 8.3.
5. General Conditions:
The undersigned applicant understands that this application is to be considered complete when
all information and documents required by the Agency have been submitted. The Agency may
request additional information to properly evaluate the proposed activities pursuant to the
regulations. The undersigned warrants the truth of all statements contained herein and in all
supporting document according to the best of his/her knowledge. The applicant further
understands that any violation of any provision of a permit may result in orders to cease and
desist from any and all work at the site. The undersigned applicant hereby consents to desist
from any and all work at the site. The undersigned applicant herby consents to necessary and
proper inspections of the subject property by authorized agents of the Agency.
____________________________ __________________________ ___________
Signature of Applicant Printed Name & Title Date
_______________________________ _____________________________ ____________
Signature of Owner Printed Name Date
Application Checklist
(For Agency Use Only)
(Section 7.5)
Application Number: __________________ Fee Paid: ____________________
List of Abutting Property Owners: ________ Site Plans/Applications: _________
Applicant Statement: __________________ Inspection Authorization Letter: ______
CT DEEP Reporting Form: _____________
9/2017
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Inland Wetlands and Watercourses Agency (City of Bridgeport)

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Completed 15 February 2021

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