Section VI: Self-Verification Notification Form 

(for all tidal and non-tidal projects in Maine subject to Corps jurisdiction) 









At least two weeks before work commences, complete all fields (write “none” if applicable) below or use the fillable form 
found at www.nae.usace.army.mil/Missions/Regulatory/State-General-Permits/Maine-General-Permit/ The two-week lead time is 
not required for emergency situations. Send this form, an Official Species List, and project plans to the following 
email address: cenae-r-me@usace.army.mil 

Maine Project Office State Permit #: 

U.S. Army Corps of Engineers 

442 Civic Center Drive, Suite 350 





Date of State Permit: 

State Project Manager: 

Augusta, Maine 04330 

Permittee: 









Address, City, State, Zip: 









Email, Phone: 









Agent: 









Address, City, State, Zip: 









Email, Phone: 









Contractor: 









Address, City, State, Zip: 









Email, Phone: 









Project Name: 









Address, City, State, Zip: 









Lat °N, Long °W: 





Tax Map/Lot: 



Waterway Name: 









Description of Work: 



















Proposed Starting Date: 





Proposed Finish Date: 



Area of wetland impact (SF): 

Permanent: 



Temporary: 



Area of waterway impact (SF): 

Permanent: 



Temporary: 



Work will be done under the following Section V General Permits (circle all that apply): 

I. Inland Waters and wetlands: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 

II. Navigable Waters: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 

Have MHPC and all five federally-recognized tribes in Maine been notified of the proposed work? Yes No 



Your signature below, as permittee, indicates that you accept and agree to comply with the terms, eligibility criteria, and 
general conditions for Self-Verification under the Maine General Permit. 





Permittee Signature: Date: