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Home My WebLink AboutNOI4 Massachusetts Department of Environmental Protection Provided by MassDEP Bureau of Resource Protection - Wetlands WPA Form 3 — Notice of intent kmisDEPFiie'Numte� _. .._ Massachusetts Wetlands Protection Act M G.L. C. 131, §40 i curn8nt Transaction Number Town of Yarmouth Wetland By -Law, Chapter 143 Important: CityJTown When filling out A. General Information forms on the computer. use only the tab key to move your cursor - do not use the return key rah rmr,+ Note Before completing this form consult your local Conservation Commission regarding any municipal bylaw or ordinance I Project Location (Note: electronic filers will click on button to locate project site). a. Street Address rte' b Cityrrow� c Zip Code Latitude and Longitude '-(l 038'5S.(P'tV 70r'id r 37 (o"(,43 3 3 d Latitude R e Longitude f Assessors Map/Plat Number 1 ` C:V g Parcel /Lot Nu ber 2. Applicant me First Name b Last Name c Organization as +-�o (L(-( ane d Street Address e. City/Town Sbg._ 3 jt y h Phone Number I Fax Number f State g Zip Code nD C.onncas_j. r)Cj- 1 Email Address 3. Property owner (required if different from applicant): ❑ Check if more than one owner a First Name b Last Name C Organization d Street Address e. CltyrTown f State g Zip Code h. Phone Number Fax Number j Email address 4 Representative (if any): a. First Name b Last Name c Company d. Street Address e City/Town f State g Zip Code h. Phone Number I. Fax Number i Email address 5. Total WPA Fee Paid (from NOI Wetland Fee Transmittal Form). ,$ r r o 9(40.5-0 11 co 7. so a Total Fee Paid b State Fee PaEd C CitylTown Fee Paid wpaform3 doc • rev. 611$12020 Page 1 of 9 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands WPA Form 3 — Notice of Intent Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Town of Yarmouth Wetland By -Law, Chapter 143 A. General Information (continued) 4 Provided by MassDEP MassDEP File Number Document Transaction Number City/Town 6 General Project Description: Vk>C'_\-.• . 4.411,f 1P �— j��Cyr _]� ,r., �, �,� t. r r C� t~C.� ft 3 i, 7a. Project Type Checklist (Limited Project Types see Section A 7b.) 1 X Single Family Home 3 ❑ Commercial/Industrial 5. ❑ Utilities 7 ❑ Agriculture (e.g., cranberries, forestry) 9. ❑ Other 2 ❑ Residential Subdivision 4. ❑ Dock/Pier 6. ❑ Coastal engineering Structure 8 ❑ Transportation 7b is any portion of the proposed activity eligible to be treated as a limited project (including Ecological Restoration Limited Project) subject to 310 CMR 1024 (coastal) or 310 CMR 10.53 (inland)? ❑ Yes [� No If yes. describe which limited protect applies to this project (See 310 CMR 10.24 and 10 53 for a complete list and description of limited project types) 2, Limited Project Type If the proposed activity is eligible to be treated as an Ecological Restoration Limited Project (310 CMR 10.24(8), 310 CMR 10 53(4)), complete and attach Appendix A Ecological Restoration Limited Project Checklist and Signed Certification 8. Property recorded at the Registry of Deeds for Cxc,<cvsQb �2 a County b Certificate # (if registered land) c Book d Page N3 CS? er B. Buffer Zone & Resource Area Impacts (temporary S permanent) 1. ❑ Buffer Zone Only — Check if the project is located only In the Buffer Zone of a Bordering Vegetated Wetland, Inland Bank. or Coastal Resource Area. 2 ❑ Inland Resource Areas (see 310 CMR 10.54-10.58. if not applicable, go to Section B 3, Coastal Resource Areas). Check all that apply below Attach narrative and any supporting documentation describing how the project will meet all performance standards for each of the resource areas altered, including standards requiring consideration of alternative project design or location. wpaform3.doc -rev 611812020 Page 2 of 9 4 Massachusetts Department of Environmental Protection Provided byMassDEP: Bureau of Resource Protection - Wetlands _ __ ___ LlWPA Form 3 --Notice of Intent MassDEP File Number _ Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 °ocir"e"tTransactw"t�lumrper Town of Yarmouth Wetland By -Law, Chapter 143 City/Town B. Buffer ZOlie $c ReSoiJrCE' Asea I111paCtS (temporary8. permanent) (cont'd) Resource Area e ❑ Isolated Land Subject to Flooding Size of Proposed Alteration 1 linear feet 1 square feel 1 -square feet 3. cubic yards dredged Stze�osed Alteration 1 square feet 3 cubic feet of flood storage lost 1 square feet Proposed Replacement if an 2 linear feet 2 square feet 2 square feet Pro osed Re lacement if an 2. square feet 4. cubic feet rep€aced 2. cubic feet of flood storage lost 3 cubic feet replaced f El Riverfront Area 1 Name of Waterway (if available) - specify coastal or inland 2. Width of Riverfront Area (check one) ❑ 25 ft - Designated Densely Developed Areas only ❑ 100 ft. - New agricultural projects only ❑ 200 ft. - All other projects 3 Total area of Riverfront Area on the site of the proposed project: square feet 4 Proposed alteration of the Riverfront Area. a total square feet b. square feet within 100 ft c square feet between 100 ft. and 200 ft s Has an alternatives analysis been done and is it attached to this NOI? ❑ Yes ❑ No 6 Was the lot where the activity is proposed created prior to August 1, 1996? ❑ Yes ❑ No 3. Coastal Resource Areas: (See 310 CMR 10.25-10 35) Note: for coastal riverfront areas, please complete Section B.2.f above wpaform3 doc - rev. 611812020 Page 3 of 9 a. ❑ Bank For all projects affecting other b ❑ Bordering Vegetated Resource Areas. Wetland please attach a narrative c ❑ Land Under explaining how the resource Waterbodies and area was Waterways delineated Resource Area d ❑ Bordering Land Subject to Flooding e ❑ Isolated Land Subject to Flooding Size of Proposed Alteration 1 linear feet 1 square feel 1 -square feet 3. cubic yards dredged Stze�osed Alteration 1 square feet 3 cubic feet of flood storage lost 1 square feet Proposed Replacement if an 2 linear feet 2 square feet 2 square feet Pro osed Re lacement if an 2. square feet 4. cubic feet rep€aced 2. cubic feet of flood storage lost 3 cubic feet replaced f El Riverfront Area 1 Name of Waterway (if available) - specify coastal or inland 2. Width of Riverfront Area (check one) ❑ 25 ft - Designated Densely Developed Areas only ❑ 100 ft. - New agricultural projects only ❑ 200 ft. - All other projects 3 Total area of Riverfront Area on the site of the proposed project: square feet 4 Proposed alteration of the Riverfront Area. a total square feet b. square feet within 100 ft c square feet between 100 ft. and 200 ft s Has an alternatives analysis been done and is it attached to this NOI? ❑ Yes ❑ No 6 Was the lot where the activity is proposed created prior to August 1, 1996? ❑ Yes ❑ No 3. Coastal Resource Areas: (See 310 CMR 10.25-10 35) Note: for coastal riverfront areas, please complete Section B.2.f above wpaform3 doc - rev. 611812020 Page 3 of 9 4 Massachusetts Department of Environmental Protection Provided by MassDEP Bureau of Resource Protection - Wetlands WPA Form 3 - Notice of Intent MassDEP File Number_ Massachusetts Wetlands Protection Act M G.L. c. 131, §40 DocumentTransaclion-Number Town of Yarmouth Wetland By -Law, Chapter 143 City/Town B. Buffer Zone & Resource Area Impacts (temporary & permanent) (cont'd) Check all that apply below. Attach narrative and supporting documentation describing how the project will meet all performance standards for each of the resource areas altered, including standards requiring consideration of alternative project design or location Online Users: Include your Resource Area Size of Proposed Alteration Proposed Replacement it an document transaction number (provided on your receipt page) with all supplementary information you submit to the Department. a ❑ Des#gnated Port Areas b. ❑ Land Under the Ocean c ❑ Barrier Beach d ❑ Coastal Beaches e ❑ Coastal Dunes f ❑ Coastal Banks g ❑ Rocky Intertidal Shores h ❑ Salt Marshes ❑ Land Under Salt Ponds 1 ❑ Land Containing Shellfish k ❑ Fish Runs Indicate size under Land Under the Ocean. below 1 square feet 2 cubic yards dredged Indicate size under Coastal Beaches and/or Coastal Dunes below 1 square feet 1. square feet Size_ of Proposed Alteration 1 Itnear feet 1 square feet 1. square feet 1 square feet 2 cubic yards dredged 1 square feet 2 cuOic yards beach nourishment 2 cubic yards dune nourishment Proposed Replacement jif an 2 sq ft restoration, rehab., creation Indicate size under Coastal Banks. inland Bank, Land Under the Ocean, andlor inland Land Under Waterbodies and Waterways, above 1 cubic yards dredged Land Subject to 5 -7 Coastal Storm Flowage 1. square feet r 4. ❑ Restoration/Enhancement If the project is for the purpose of restoring or enhancing a wetland resource area In addition to the square footage that has been entered in Section B 2 b or $.3 h above, please enter the additional amount here. a square feet of Bvvv 5. ❑ Project involves Stream Crossings a number of new stream crossings b. square feet of Salt Marsh In number of replacement stream crossings wpaformIdoc • rev W18/2020 Page 4 of 9 Massachusetts Department of Environmental Protection Provided by MassDEP Bureau of Resource Protection - Wetlands MassDEP File Number WPA Form 3 - Notice of Intent Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Town of Yarmouth Wetland By -Law, Chapter 143 C. Other Applicable Standards and Requirements Document Transaction t umber City/Town ❑ This is a proposal for an Ecological Restoration Limited Project Skip Section C and complete Appendix A: Ecological Restoration Limited Project Checklists — Required Actions (310 CMR 10 11) Streamlined Massachusetts Endangered Species Act(Wetlands Protection Act Review 1 Is any portion of the proposed project located in Estimated Habitat of Rare Wildlife as indicated on the most recent Estimated Habitat Map of State -Listed Rare Wetland Wildlife published by the Natural Heritage and Endangered Species Program (NHESP)? To view habitat maps see the Massachusetts Natural Heritage Atlas or go to htt Alma s mass is state ma us/PRI EST HABlviewer.htm. a ❑ Yes K No If yes, include proof of mailing or hand delivery of NOI to: Natural Heritage and Endangered Species Program Division of Fisheries and Wildlife 1 Rabbit Hill Road b Date of map Westborough, MA 01581 If yes, the project is also subject to Massachusetts Endangered Species Act (MESA) review (321 CMR 10 18). To qualify for a streamlined, 30 -day MESA/Wetlands Protection Act review, please complete Section C.1 c, and include requested materials with this Notice of Intent (NOI), OP complete Section C.2 f, if applicable. If MESA supplemental information is not included with the NO], by completing Section 1 of this form, the NHESP will require a separate MESA filing which may take up to 90 days to review (unless noted exceptions in Section 2 apply, see below). c. Submit Supplemental Information for Endangered Species Review' t ❑ Percentage/acreage of property to be altered (ap within wetland Resource Area percentagetacreage (b) outs+de Resource Area percentagelacreage 2 ❑ Assessor's Map or right-of-way plan of site ❑ Project plans for entire project site, including wetland resource areas and areas outside of wetlands jurisdiction, showing existing and proposed conditions, existing and proposed tree/vegetation clearing line, and clearly demarcated limits of work - W ❑ Project description (including description of impacts outside of wetland resource area & buffer zone) (b) ❑ Photographs representative of the site Some projects not in Estimated Habitat may be located in Priority Habitat, and require NHESP review (see htt s:Nwww mass. ov/ma- endan ered-s ecies-act-mesa-re(julato -review) Priority Habitat includes habitat for state -listed plants and strictly upland species not protected by the Wetlands Protection Act MESA projects may not be segmented (321 CMR 10 16) The applicant must disclose full development pians even if such plans are not required as part of the Notice of Intent process. wnafnrml rknr . rav A» str?nr)n Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands WPA Form 3 - Notice of Intent Massachusetts Wetlands Protection Act M G.L. c. 131. §40 Town of Yarmouth Wetland By -Law, Chapter 143 4 Provided by MassDEP. MassDEP File Number Document Transaction Number City/Town C. other Applicable Standards and Requirements (cont'd) (c) ❑ MESA filing fee (fee information available at htt s llwwwmass govihow-to/how-to-file-for- a-me sa-p ro ect-review) Make check payable to "Commonwealth of Massachusetts - NHESP" and mail to NHESP at above address Projects altering 10 or more acres of laird, also submit: (d) ❑ Vegetation cover type map of site (e) ❑ Project plans showing Priority & Estimated Habitat boundaries (t) OR Check One of the Following i ❑ Protect is exempt from MESA review Attach applicant letter indicating which MESA exemption applies. (See 321 CMR 10.14, htt s //www.mass. ov/servir-e-details/exem tions-from-rev+ew-for- ro ectsactivities-in- prioritV-habitat. the NOI must still be sent to NHESP if the protect is within estimated habitat pursuant to 310 CMR 10.37 and 10.59.) 2 ❑ Separate MESA review ongoing. a. NHESP Trackin t 9 b. Date submitted to NHESP 3. ❑ Separate MESA review completed. Include copy of NHESP "no Take" determination or valid Conservation & Management Permit with approved plan 3. For coastal projects only, is any portion of the proposed project located below the mean high water line or in a fish run'? a l< Not applicable — project is in inland resource area only b ❑ Yes ❑ No If yes, include proof of mailing, hand delivery, or electronic delivery of NOI to either South Shore - Cohassel to Rhode Island border, and the Cape & Islands: Division of Marine Fisheries - Southeast Marine Fisheries Station Attn: Environmental Reviewer 836 South Rodney French Blvd. New Bedford, MA 02744 Email: dmf envreview-south mass ov North Shore - Hull to New Hampshire border: Division of Marine Fisheries - North Shore Office Attn: Environmental Reviewer 30 Emerson Avenue Gloucester, MA 01930 Email dmf.envrevievr-north mass�gov Also if yes, the project may require a Chapter 91 license. For coastal towns in the Northeast Region. please contact MassDEP's Boston Office For coastal towns in the Southeast Region. please contact MassDEP's Southeast Regional Office. c ❑ Is this an aquaculture protect? d ❑ Yes VNo If yes, include a copy of the Division of Marine Fisheries Certification Letter (M.G L. c 130. § 57) wpaform3 doc • rev. 6/18/2020 Page 6 of 9 4 Massachusetts Department of Environmental Protection Provided by MassDEP. Bureau of Resource Protection - Wetlands WPA Form 3— Notice of Intent MassDEP File Number Massachusetts Wetlands Protection Act M.G.L. c. 131, X40 OocumentTransamonNumber Town of Yarmouth Wetland By -Law, Chapter 143 City/Town C. Other Applicable Standards and Requirements (cont'd) 4 Is any portion of the proposed project within an Area of Critical Environmental Concern (ACEC)? Online Users: a ❑ Yes I& No If yes, provide name of ACEC (see instructions to WPA Form 3 or MassDEP Include your Website for ACEC locations). Note: electronic filers click on Website. document transaction b ACEC number (provided on your 5. Is any portion of the proposed project within an area designated as an Outstanding Resource Water receipt page) (ORM as designated in the Massachusetts Surface Water Quality Standards, 314 CMR 4 00? with all supplementary a ❑ Yes Department. No information you submit to the 6 Is any portion of the site subject to a Wetlands Restriction Order under the Inland Wetlands Restriction Act M G.L. c. 131, § 40A) or the Coastal Wetlands Restriction Act (M.G L c. 130, § 105)? a ❑ Yes No 7. Is this project subject to provisions of the MassDEP Stormwater Management Standards? a ❑ Yes. Attach a copy of the Stormwater Report as required by the Stormwater Management Standards per 310 CMR 10.05(6)(k) -(q) and check if 1 ❑ Applying for Low Impact Development (LID) site design credits (as described in Stormwater Management Handbook Vol 2, Chapter 3) 2 ❑ A portion of the site constitutes redevelopment �,,(3. ❑ Proprietary BMPs are included in the Stormwater Management System b. J� No Check why the project is exempt XSingle-family house 2 ❑ Emergency road repair 3. ❑ Small Residential Subdivision (less than or equal to 4 single-family houses or less than or equal to 4 units in multi -family housi D. Additional Information Wroject) with no discharge to Critical Areas. -- ❑ This Is a proposal for an Ecological Restoration Limited Project Skip Section D and complete Appendix X Ecological Restoration Notice of Intent — Minimum Required Documents (310 CMR 10 12). Applicants must include the following with this Notice of Intent (NOI) See instructions for details Online Users: Attach the document transaction number (prov)ded on your receipt page) for any of the following information you submit to the Department ❑ LISGS or other map of the area (along with a narrative description. if necessary) containing sufficient information for the Conservation Commission and the Department to locate the site (Electronic filers may omit this item ) 2 ❑ Plans identifying the location of proposed activities (including activities proposed to serve as a Bordering Vegetated Wetland {BVW] replication area or other mitigating measure) relative to the boundaries of each affected resource area wpaform3.doc • rev 611812020 Page 7 of 9 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands WPA Form 3 - Notice of intent Massachusetts Wetlands Protection Act M.G.L. c 131, X40 Town of Yarmouth Wetland By -Law, Chapter 143 D. Additional Information (cortt'd) .- 4 Provided by MassDEP: MassDEP File Number Document Transaction Number City/Town 3 3. ❑ Identify the method for BVW and other resource area boundary delineations {MassDEP BVW Field Data Form(s). Determination of Applicability, Order of Resource Area Delineation, etc ). and attach documentation of the methodology 4. List the titles and dates for all plans and other materials submitted with this NOI �. Plan .(Title b. Prep a d 8y c Signed and Stamped by d Final Revision Date1 H r e. Scale f Additional Plan or Document Title g Date 5- ❑ If there is more than one property owner. please attach a list of these property owners not listed on this form. B. ❑ Attach proof of mailing for Natural Heritage and Endangered Species Program if needed 7 ❑ Attach proof of mailing for Massachusetts Division of Marine Fisheries, if needed. s. Attach NOI Wetland Fee Transmittal Form 9. ❑ Attach Stormwater Report, if needed. E. Fees t ❑ Fee Exempt No filing fee Shall be assessed for projects of any city, town, county, or district of the Commonwealth, federally recognized Indian tribe housing authority, municipal housing authority, or the Massachusetts Bay Transportation Authority Applicants must submit the following information (in addition to pages 1 and 2 of the NOI Wetland Fee Transmittal Form) to confirm fee payment; �/ t k� 2. Municip 1 heck Number 3. Check dat 4. State Check Number / I 5 Check date 6 Payor name on check. First Name 7 Payor namEcheck Last Name wpaform3.00c • rev 6/18/2020 Page 8 of 9 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands WPA Form 3 - Notice of Intent Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Town of Yarmouth Wetland By -Law, Chapter 143 F. Signatures and Submittal Requirements 4 Provided by MassDEP: MassDEP File Number t)ocument Trensactian Number CitylTown I hereby certify under the penalties of perjury that the foregoing Notice of Intent and accompanying plans, documents, and supporting data are true and Complete to the best of my knowledge I understand that the Conservation Commission will place notification of this Notice in a local newspaper at the expense of the applicant in accordance with the wetlands regulations. 310 CMR 10 05(5)(a) I further certify under penalties of perjury that all abutters were notified of this application. pursuant to the require nts of M.G L c. 131, § 40 Notice must be made by Certificate of Mailing or in writing by hand delivor certified mail (return receipt requested) to all abutters within 100 feet f the roperty line of the pr ec locationenkure nt 2 Dated q y Owner 4 Date 5 Signatureof Representative (if any) 6 Date For Conservation Commission: Two copies of the completed Notice of Intent (Form 3), including supporting plans and documents, two copies of the NOI Wetland Fee Transmittal Form, and the city/town fee payment, to the Conservation Commission by certified mat] or hand delivery, For MassDEP: One copy of the completed Notice of Intent (Form 3), including supporting plans and documents, one copy of the NOI Wetland Fee Transmittal Form, and a copy of the state fee payment to the MassDEP Regional Office (see Instructions) by certified mail or hand delivery Other: If the applicant has checked the yes' box in any part of Section G, Item 3, above, refer to that section and the Instructions for additional submittal requirements. The original and copies must be sent simultaneously. Failure by the applicant to send copies in a timely manner may result in dismissal of the Notice of Intent wpaform3.dac - rev. 6/18/2020 Page 9 of 9 LLAMassachusetts Department of Environmental Protection Bureau Of Resource Protection - Wetlands NO[ Wetland Fee Transmittal Form Massachusetts Wetlands Protection Act M G.L. c. 131, §40 Important: When A. Applicant Information filling out forms on the computer, 1 Location of Project: use only the tab key to move your cursor - do return a not 0 use the retStreet Address Key c Check number 2. Applicant Mailing Addre s: 4 � X ('c St"_ a. First Name c. Organization as -4n(Ly d Mailing Addfess 5 6v e City/Town � � SDS _� S() ~l(D,? C( h Phone Number i. Fax Number 3. Property Owner (if different) - a. First Name c. Organization d Mailing Address b City/Town d Fee amount b Last Name (YU � �! f Stale � g Zip Code j Email Address r,,r GLJ � ` �'t • jL' b Last Name e City/Town f State g ZIP Code h. Phone Number Fax Number To Calculate -- ----� _ ; Email Address filing fees refer B. Fees to the category fee list and Fee should be calculated using the following process & worksheet Please see Instructions before examples in the filling out worksheet. instructions for filling out WPA Ste 11? Form 3 (Nonce of p YPe of Activity: Describe each type of activity that will occur in wetland resource area and buffer zone. Intent). Step 2/Number of Activities. Identify the number of each type of activity. Step 311ndividual Activity Fee. Identify each activity fee from the six project categories listed in the instructions. Step 4/Subtotal Activity Fee: Multiply the number of activities (identified in Step 2) times the fee per category (identified in Step 3) to reach a subtotal fee amount. Note If any of these activities are in a Riveriront Area in addition to another Resource Area or the Buffer Zone, the fee per activity should be multiplied by 1 5 and then added to the subtotal amount. Step 51TotaI Project Fee: Determine the total project fee by adding the subtotal amounts from Step 4 Step 6/Fee Payments: To calculate the state share of the fee, divide the total fee in half and subtract $12 50 To calculate the city/town share of the fee, divide the total fee in half and add $12.50. nodeett Cl-. W91iarta Fee Transmittal Form -rev 10111 Page 1 or Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands NOI Wetland Fee Transmittal Form Massachusetts Wetlands Protection Act M G.L. c. 131, §40 B. Fees (continued) Step 1/Type of Activity Step 2/Number of Activities Step Undividual Activity Fee / / c - Step 5/Total Project Fee: Step 6/Fee Payments. Total Project Fee State share of filing Fee City/Town share of filling Fee: C. Submittal Requirements Step 4/Subtotal Activity Fee a Total Fee from Step 5 b 112 Total Fee less $12.5o c- 112 Total Fee plus $12.50 a ) Complete pages i and 2 and send with a check or money order for the state share of the tee payable to the Commonwealth of Massachusetts. Department of Environmental Protection Box 4062 Boston MA 02211 b.) To the Conservation Commission: Send the Notice of Intent or Abbreviated Notice of Intent, a copy of this form, and the city/town fee payment. To MassDEP Regional Office (see instructions) Send a copy of the Notice of Intent or Abbreviated Notice of Intent, a copy of this form. and a copy of the state fee payment. (E -filers of Notices of Intent may submit these electronically.) nodaeH doc • V*Wrxl Fee Trans MW Foran • rev I&I 7 Page 2 0! 2 Proposed addition for 22 Holly Lane South Yarmouth, MA - Demolish three season room Build living room and third bedroom on a frost wall/ crawl space foundation attached to existing house - Add farmers porch to front of house Property is in a flood zone. It does not abut wetlands or conservation land. The proposed project meets all of the applicable regulations of the Town of Yarmouth zoning bylaws. RECEIPT Domestic Mail only For delivery information, visit our website at www.usps.com`. t PS Form 300, April 2015 PSN 400-9W Seo Reverse for Inelruclions CERTIFIEDNAWU-.�� m Domestic Ill Only CrEr �•a � �ftM � _ _ k • oQvev�N�ON �/ ru :414nn :wcz,ll V'•alUtxYrY7 S r Q ._� Rr:urn I,ece.Vl felsr-trmlc) S •y1r1� ,: C) Wn+. a+ami NelektM [sdn+aY Sn 4/i lA/ ru _ C :al Post cgc a Fps /�A g�01.. ru I 0 Domestic Only Fri 7 i -� - . 0 44 'IT p ital Postage and Feem Or 1r / - ru 01 i (7d�ti U.S. Postal Service`" CERTIFIED MAIV RECEIPT Domestic Mail Only u'For delivery information, visit our website at www.uspls.com'. s 1 s • • I FS Form 3800, April 2015 PSN 75:111.02-m W47 Sea Reverse for Inatructiorls �n M Q c .,, . :. ANION s o P Cr- �� oDomestic Domestic Mail Only Mail nly Qom" CO S =- -, � '• J•�' ee Cl CO t CD {71 � .{' . d gce C7V M SEP 2 a 2w C3 a Cr- �n Cl __,-/ Domestic Mail Only Qom" CO S =- -, � '• l Cl CO t CD ru ru I POdtme and Fojp; � .{' . d gce