USACE Permit ApplicationDEPARTMENT OF THE ARMY
U.S. Army Corps of Engineers, ATTN: CENAN-OP-RU
Upstate Regulatory Field Office
1 Buffington St., Building 10, 3 rd Fl. North
Watervliet, New York 12189-4000
CENAN-OP-RU
NATIONWIDE PERMIT COMPLIANCE CERTIFICATION AND REPORT FORM
Permittee: Nick Giumarra Permit No. NAN-2020-01175-UPO
Date Permit Verification Issued: December 30, 2021
Location: 373 Big Boom Road (Lot 5), Town of Queensbury , Warren County, New York
Within 30 days of the completion of the activity authorized by this permit and any mitigation required by the
permit, sign this certification and return it to the address at the bottom of this form.
Please note that your permitted activity is subject to a compliance inspection by a U.S. Army Corps of Engineers
representative. If you fail to comply with this permit, you are subject to permit suspension, modification, or
revocation.
I hereby certify that the work authorized by the above referenced permit has been completed in accordance with
the terms and conditions of said permit, and required mitigation was completed in accordance with the permit
conditions.
Date Work Started: ____________________
Date Work Completed: ____________________
________________________________________ _____________________
Signature of Permittee Date
Fold this form into thirds, with the bottom third facing outward. Tape it together and mail to the address below
or EMAIL TO: cenan.rfo@usace.army.mil
___________________ Place Stamp
___________________ Here
___________________
DEPARTMENT OF THE ARMY
U.S. Army Corps of Engineers
ATTN: CENAN-OP-RU
Upstate Regulatory Field Office
1 Buffington St., Bldg. 10, 3rd Fl. North
Watervliet, New York 12189-4000