JOINT APPLICATION FORM – Continued. Submit this completed page as part of your Application.
Applicant and Owner (If different) must sign the application.
Append additional pages of this Signature section if there are multiple Applicants, Owners or Contact/Agents.
I hereby affirm that information provided on this form and all attachments submitted herewith is true to the best of
my knowledge and belief.
Permission to Inspect - I hereby consent to Agency inspection of the project site and adjacent property areas.
Agency staff may enter the property without notice between 7:00 am and 7:00 pm, Monday - Friday. Inspection
may occur without the owner, applicant or agent present. If the property is posted with "keep out" signs or fenced
with an unlocked gate, Agency staff may still enter the property. Agency staff may take measurements, analyze
site physical characteristics, take soil and vegetation samples, sketch and photograph the site. I understand that
failure to give this consent may result in denial of the permit(s) sought by this application.
False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the NYS
Penal Law. Further, the applicant accepts full responsibility for all damage, direct or indirect, of whatever n
and by whomever suffered, arising out of the project described herein and agrees to indemnify and save harmless
the State from suits, actions, damages and costs of every name and description resulting from said project. In
addition, Federal Law, 18 U.S.C., Section 1001 provides for a fine of not more than $10,000 or imprisonment for
not more than 5 years, or both where an applicant knowingly and willingly falsifies, conceals, or covers up a
material fact; or knowingly makes or uses a false, fictitious or fraudulent statement.
Applicant Must be (check all that apply):
Signature of Owner (if different than Applicant)
Signature of Contact / Agent
For Agency Use Only DETERMINATION OF NO PERMIT REQUIRED
Agency Application Number
(Agency Name) has determined that No Permit is
required from this Agency for the project described in this application.
JOINT APPLICATION FORM 08/16 Page 4 of 4