CITY OF COLD SPRING
STORMWATER CREDIT APPLICATION FORM
One Time Application (Page 1 of 2)
SECTION A - APPLICANT
Name: ___________________________________________________________________________________________
Address: _________________________________________________________________________________________
City: _____________________________________________ State: __________________ Zip: ___________________
Phone: ( ) ______________________________________ Fax: ( ) ______________________________________
Email: ___________________________________________________________________________________________
SECTION B - SITE INFORMATION
Name: ___________________________________________________________________________________________
Real estate tax bill parcel number: _______________________________________________________________________
Location: _________________________________________________________________________________________
________________________________________________________________________________________________
Type of management practice: _________________________________________________________________________
Impervious area: ___________________________________________________________________________________
SECTION C - ENGINEER OF RECORD
Name: __________________________________________________________________________________________
Company:________________________________________________________________________________________
Address: _________________________________________________________________________________________
City: ______________________________________________ State: __________________ Zip: __________________
Phone: ( ) ___________________________________ Fax: ( ) _________________________________________
Email: ____________________________________________________________________________________________
CITY OF COLD SPRING
STORMWATER CREDIT APPLICATION FORM
One Time Application (Page 2 of 2)
CERTIFICATION:
I hereby request consideration for a stormwater credit. I certify that I have authority to make such a request and authorization for this property. I further certify that the above information is true and correct to the best of my knowledge and belief. I agree to maintain the above stated management practice to the prescribed criteria according to the City of Cold Spring Stormwater Program. I hereby release the City of Cold Spring Stormwater Program from any maintenance responsibility whatsoever on the above identified management practice located on my property. I agree to provide corrected information should there be any change in the information provided herein.
A. ENGINEER SEAL
___________________________________________________ _____________________________________________
Name Title
___________________________________________________ _____________________________________________
Signature Date
(Ord. 14-1003, passed 5-12-14)