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Home My WebLink AboutRDA application formImportant: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Massachusetts Department of Environmental Protection Yarmouth Bureau of Resource Protection - Wetlands Cityrrown WPA Form 1- Request for Determination of Applicability Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 A. General Information Ap Kant: S b� b� I�er5 Name E-Mail Address Z.G— Mailing Address CitylTown w � O (0State Zip Cade Phone Nuftt6er I Fax Number (if applicable) Representative (if any): Firm Mailing Address City/Town Phone Number B. Determinations 1. 1 request the Conservation Commission E;-Mail Address State Zip Code Fax Number (if applicable) make the following determination (s). Check any that apply: 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. Vc. whether the work depicted on plan(s) referenced below is subject to the Wetlands Protection Act. [f 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 M e.-V�fiether the following scope of alternatives is adequate for work in the Riverfront Area as depicted on referenced plan(s). wpaforrnt.doc - rev. 7/27/2020 WPA Forth 1 — Request for Determination of Applicability - Page 1 of 4 LillMassachusetts Department of Environmental Protection Yarmouth Bureau of Resource Protection - Wetlands atyrrowR- 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 A dress City/Town Asse sors lvapIPWNumber Parcel/Lot Number b. Area Description (use additional paper, if necess m, Alta( Frzc w— A b ►Ti of 3 F / x 3�11 c. Plan and/or Map Reference(s): Pay QilN-VV (;'(-- PRcA(r t4--)I Title Title aoa� Date Date Date 2. a. Work Description (use additional paper and/or provide plan(s) of work, if necessary): fle-61AIr- AWrnoe Io'XHId wpafarml.doc - rev. 7/27/2020 WPA Farm 1 — Request for Determination of Applicability • Page 2 of 4 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands yew° --- CitylTown WPA Form 1- Request for Determination of Applicability LI-1 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). 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 811/96 ❑ 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.) wpaforrnl.doc • rev. 7/27/2020 WPA Form 1 — Request for Determination of Applicability • Page 3 of 4 LillMassachusetts Department of Environmental Protection Yarmouth Bureau of Resource Protection - Wetlands CtylTown WPA Form I - Request for Determination of Applicability 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 Gltyl I own 73 State Zip Code Signatures: I also understand that notification of this Request will be placed in a local newspaper at my expense in accordance wi cti 10.05(3)(b)(1) of the Wetlands Protection Act regulations. L'z 3 1z0 z Signature Applicant Date � 32 Q Z � Signature of Representative (if any) Date wpaforml.doc • rev. 7/27/2020 WPA Form 9 — Request for Determination of Applicability • Page 4 of 4