HomeMy WebLinkAboutRDAMassachusetts Department of Environmental Protection
Bureau of Resource Protection - Wetlands
Yarmouth
WPA Form 1- Request for Determination of Applicability City/Town
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40
A. General Information
Important:
When filling out
1 • Applicant:
formthe
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Name 3
E-Mail Address
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Mailing Address
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State Zip Code
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Phone Number
Fax Number (if applicable)
2. Representative (if any):
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Firm
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Contact Name I
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E-Mail Address
Mailing Address
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State Zip Code
Phone Number
Fax Number (if applicable)
B. Determinations
I request the make the following determination(s). Check any that apply:
Conservation Commission
❑ a. whether the area depicted on plan(s) and/or map(s) referenced below is an area subject to
jurisdiction of the Wetlands Protection Act:
❑ b. whether the boundaries of resource area(s) depicted on plan(s) and/or map(s) referenced
below are accurately delineated.
[)c. whether the work depicted on plan(s) referenced below is subject to the Wetlands Protection Act.
❑ d. whether the area and/or work depicted on plan(s) referenced below is subject to the jurisdiction
of any municipal wetlands ordinance or bylaw of:
Name of Mu
❑ e. whether the following scope of alternatives is adequate for work in the Riverfront Area as
depicted on referenced plan(s).
wpaforml.doc • rev. 7/27/2020
WPA Form 1 — Request for Determination of Applicability • Page 1 of 4
Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Wetlands Yarmouth
city/Town
WPA Form 1- Request for Determination of Applicability
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):
Street Address — City/Town
Assessors Map/Plat Number
W- 3O
Parcel/Lot Number
b. Area Description (use additional paper, if necessary):
i�Sid ;.s/T�y h'a�1E o.✓ �.QlU.4?� ryir9�, /j/a wGT SV cr7 2
c. Plan and/or Map Reference(s):
01OT i?i��
Title
Title
3 z, 20l0
Dat
/2 2,0 2Z
Date
Date
2. a. Work Description (use additional paper and/or provide plan(s) of work, if necessary):
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wpaforml.doc • rev. 7/27/2020
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WPA Form 1 — Request for Determination of Applicability • Page 2 of 4
LlMassachusetts Department of Environmental Protection
Bureau of Resource Protection - Wetlands Yarmouth
WPA Form l - Request for Determination of Applicability cityrrown
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40
C. Project Description (cont.)
b. Identify provisions of the Wetlands Protection Act or regulations which may exempt the applicant
from having to file a Notice of Intent for all or part of the described work (use additional paper, if
necessary).
G�i✓b%6✓��cd,�/ tnl�,,/ fi!iry�� G✓llHiA/ Ti� Z��.Glil/� t�S
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.
kSingle 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 8/7/96
❑ New agriculture or aquaculture project
❑ Public project where funds were appropriated prior to 8/7/96
❑ 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 Engineers or 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.)
wpaforml.doc • rev. 7/27/2020
WPA Form 1 — Request for Determination of Applicability • Page 3 of 4
MaSsachusetts Department of Enviromnental Protection
Bureau of
'Resaume Protir�ion - Wegands yan-outri
WPA Form 1 - Request for Determination of Applicability,
Massachu`wfts fttlands PrOledon Act M-G-L. c- 1317 §4o
D. Signiatur" and Submittal Requ'
irements
I nefeby oeivy ur1wr the MWbea of AerjuTy Ijifit the fonoiing Rt--qtjeM for Detenninatical of A?pticabirAy
and o3"UM-19anyling pra", Ommft-.' and aupporhng datil are, mM -
knwte."e, and COMPL-te to tf- best afmy
i further Certify UAW the property onner, if different from the applicant, and the appropriate DEP Regional
office Were sent a cOmPlete CMY Of VVS ReQLwW (irKluditig ;01 appt*piW d0u Wwatio,
11) �e U .
Sim, UftartCCUslY'w'-h the submittal of this Request to the Cbrnervaticin Qxnmiswor. r'Ol
Italkire by the appkant to send copies in a Tim* rna
Determination of AppEcability, nef nvy resuft in oiam" ssal of the, Request for
Nam and address d tho FxOperty owner.
--6� '0-
Name
Ma&69
zoo
Signatizes:
1, also understand fiat notiricabon of this r 1 WiM be phiced in, a local ricwspaper;g my expense
ira a C*'N '0' 11bl,1Emmert
amft Protecton Act regul2hons.
Z"'birn. f on 053AArFZF-
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Massachusetts Department of Environmental Protection
\ti - Bureau of Resource Protection - Wetlands Yarmouth
WPA Form 1- Request for Determination of Applicability citylTown
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:
0!5I/ff .-� CkRk,5TOS D (OAA (5
Name
3 �tiLLC2�sT Kb
Mailing Address
I A ) DiC�
City/Town 2
State
Zip Code
Signatures:
also understand that notification of this Request will be placed in a local newspaper at my expense
in accordance with Section 10.05(3)(b)(1) of the Wetlands Protection Act regulations.
Signature of
uate
1 ZO
Date
wpaforrnl.doc • rev. 7/27/2020
WPA Form 1 — Request for Determination of Applicability • Page 4 of 4
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