HomeMy WebLinkAboutRDA1Massachusetts Department of Environmental Protection
-- Bureau of Resource Protection - Wetlands
WPA Form '1- Request for Determination of �
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40
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A. General Information
Yarmnr ith
vi�Yi � vrri�
icability
1. Applicant: z� I
Sid 3t�t6�1`� "t l_1�J�C'`!�/� �iitfGt ySi`c_ L'Lt
Name E-Mail'Address
r-eou`cctI
Mailing Address
City(rown state Zip Code
Phone Number
2. Representative (if any):
Firm
Contact Name
Mailing Address
City/Town
Phone Number
E -Mail
State
B. Determinations
1. 1 request themake the following dete
Conservation Commission
( a. whether the area depicted on plan(s) and/or map(s) referenced t
jurisdiction of the Wetlands Protection Act.
b. whether the boundaries of resource area(s) depicted on plan(s)
below are accurately delineated.
21c. whether the work depicted on plan(s) referenced below is subject
EO d. whether the area and/or work depicted on plan(s) referenced
of any municipal wetlands ordinance or bylaw of:
N � � YARYL/ 3 U -7 -
Name of Municipality
Zip Code
or (if applicable)
zn(s). Check any that apply:
awls an area subject to
id/or map(s) referenced
the Wetlands Protection Act.
r is subject to the jurisdiction
❑ e. whether the following scope of alternatives is adequate for wok in the Riverfront Area as
depicted on referenced plan(s).
wpaformt.doc - rev. 7127(2020 WPA Form 1 — Request for Determination of Applicability • Page 1 of 4
Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Wetlands
Yarmouth
WPA Form 1- Request for Determination of A City/Town ,
pplicabii�ty
LI Massachusetts Wetlands Protection Act M.G.L. c. 131, §40
C. Project Description
1. a. Project Location (use maps and plans to identify the location of the area subject to this request):
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Street Address cltylTown
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Assessors Map/Plat Number Parcel/Lot Number:
b. Area Description (use additional paper, if necessary):
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c. Plan and/or Map Reference(s):
Title
Date
Dat
Date
2. a. Work Description (use additional paper and/or provide plan(s) of work, if necessary):
wpaforml.doc - rev. 7127/2020
WPA Form 1 —Request for Determination of Applicability - page 2 of 4
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WPA Form 1 —Request for Determination of Applicability - page 2 of 4
Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Wetlands
Yarmouth
A Form l - Request for Determination of Applicability City/Town
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40
I
C. Project Description (cant.)
b. Identify provisions of the Wetlands Protection Act or regulations whi
from having to file a Notice of Intent for all or part of the described work
necessary).
may exempt the applicant
e additional paper, if
3_ a. If this application is a Request for Determination of Scope of Alternatives for work in the
Riverfront Area, indicate the one classification below that best describes the project.
❑ Single family house on a lot recorded on or before 8/1/96
❑ Single family house on a lot recorded after 8/1/96
❑ Expansion of an existing structure on a lot recorded after 8/1/96
❑ Project, other than a single-family house or public project, where the applicant owned the lot
before 817/96
❑ New agriculture or aquaculture project
❑ Public project where funds were appropriated prior to 8/7196
❑ Project on a lot shown on an approved, definitive subdivision plan where there is a recorded deed
restriction limiting total alteration of the Riverfront Area for the entire subdivision
❑ Residential subdivision; institutional, industrial, or commercial project
❑ Municipal project
❑ District, county, state, or federal government project
❑ Project required to evaluate off-site alternatives in more than one municipality in an
Environmental Impact Report under MEPA or in an alternatives analysis pursuant to an
application for a 404 permit from the U.S. Army Corps of Engineersor 401 Water Quality
Certification from the Department of Environmental Protection.
b. Provide evidence (e.g., record of date subdivision lot was recorded) supporting the classification
above (use additional paper and/or attach appropriate documents, if necessary.)
wpaformt.doc • rev. 7/27/2020 WPA Form 1 — Request for Determination of Applicability • Page 3 of 4
Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Wetlands Yarmouth
WPA Form '1- Request for Determination of ApplicabilityCty/Town
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40
D. Signatures and Submittal Requirements
I hereby certify under the penalties of perjury that the foregoing Request for Determination of Applicability
and accompanying plans, documents, and supporting data are true and complete to the best of my
knowledge.
I further certify that the property owner, if different from the applicant, and the appropriate DEP Regional
Office were sent a complete copy of this Request (including all appropriate documentation)
simultaneously with the submittal of this Request to the Conservation Commission.
Failure by the applicant to send copies in a timely manner may result in dismissal of the Request for
Determination of Applicability.
Name and address of the property owner:
Name
Mailing Address
City/ town _
State
Zip Code
Signatures:
I also underst d that notification of this K uest will be aced in a local newspaper at my expense
in accords e with Se 10.05(3)(b) of the Wetla rotection Act regulations.
gnature of Applicant Date
ignature of Represe five (if any)
j Date
wpaformtdoc • rev. 7/2712020
WPA Form 1 — Request for Determination of ApPlicability • Page 4 of 4
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