Looking for a Rhode Island Legal Forms And Templates? Download it for free!

STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS

RHODE ISLAND DEPARTMENT OF ENVIRONMENTAL MANAGEMENT

OFFICE OF WATER RESOURCES

APPLICATION FOR NEW OWTS DESIGNER ’S LICENSE

CLASS I, II, III, IV

This form is valid for license year beginning January 1, 2016.

FOR DEM USE ONLY

Date Received_________________

Check No.__________________

Amt. Received________________

Code 17B

INSTRUCTIONS

GENERAL INFORMATION

Read all instructions and questions carefully before completing this application.

Do not write in the boxes labeled “For DEM Use Only”.

Date of Birth _______/_______ / ________

All information must be printed in ink or type written.

Fill out all sections completely, including your signature.

_______________________________________________________________________________________________

Include the non-refundable application fee established using the table below. Fees should

First Name

Last Name

be paid by check or money order made payable to: GENERAL TREASURER, STATE OF

RHODE ISLAND.

_______________________________________________________________________________________________

Send application and fee to:

Legal Residential Mailing Address

Department of Environmental Management, Permit Application Center (PAC),

235 Promenade Street, Providence, RI 02908.

____________________________________________________________

City

State

Zip

Within 30 days of receipt of an application, the applicant shall be notified of their

eligibility status. If the applicant is deemed ineligible, the Department shall provide the

( _______ )_______________________

____________________________________________________________

applicant with reasons for the determination. The applicant may appeal the Director's

Telephone

E-mail Address

decision of ineligibility with the Administrative Adjudication Division.

LICENSE APPLICATION FEE TABLE

License

Number of Years for Which the License will be Valid

License Application Fee

Class I

2 (2016, 2017)

$100

Class II

3 (2016, 2107, 2018)

$150

Class III

3 (2016, 2017, 2018)

$150

Class IV*

1 (2016)

$50*

*If you are applying for a Class IV License and hold another Designer License, find the License Application Fee

associated with that license in the table above and pay the indicated fee. The new Cl-IV license, when issued, will

expire at the same time as the other license.

TAXPAYER CERTIFICATION

You are required to furnish your Social Security # or FEIN pursuant to Chapter 75 of Title 5 and Chapter 3 of Title 31 of the RI General Laws, as amended. Any

person applying for any license or permit to conduct a business or occupation within Rhode Island or any person renewing a motor vehicle operator’s license or

motor vehicle registration within Rhode Island must have filed all required state tax returns and paid all taxes due the state or must have entered into a written

installment agreement to pay delinquent state taxes that is satisfactory to the Tax Administrator. Failure to provide the Department with your Social Security # or

FEIN will result in you having to obtain a Letter of Good Standing from the RI Division of Taxation One Capitol Hill Providence, RI 02908 (401) 574-8941,

Collections Division PRIOR to the issuance or renewal of your license.

I hereby declare, under penalty of perjury, that I have filed all required state tax returns and have either paid all taxes due the state or have entered

into a written installment agreement with the Rhode Island Division of Taxation.

Social Security # or FEIN __________________________

Applicant’s Signature _______________________________________________________________________ Date ___________________

Printed Name _____________________________________________________________________________

If necessary, please submit Letter of Good Standing or Installment Agreement along with this completed license application as directed above in the Instructions

section of this application form.

This form expires November 1, 2016, see RIDEM website ( ) for most recent form update.

Z:\Forms\Licensing\License Apps\2016 Des Lic App\2016 Des Lic App.docx_11-3-15