HomeMy WebLinkAbout03.03.23. Great Island Homeowners.MESA App. Causeway fill (002)v.5/2022
Massachusetts Endangered Species Act M.G.L. c.131A and Regulations (321 CMR 10.00)
Project Details
*Project or Site Name: _________________________________________________________________________________________
*Street Address/Location: ______________________________________________________________________________________
*Town(s): ___________________________________________________________________________________________________
*Total Site Acreage: _________________________ *Acreage of Disturbance1: ____________________________
Parcel/lot number: __________________________ Assessors map/plat number: ____________________
Project Description (If necessary, a project/site description can also be provided as an attachment): __________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Registry of deeds information2
Registry: __________________________________ Certificate # (if registered land): _______________________________
Book: _____________________________________ Page Number: _____________________________________________
Do you have a previous NHESP Tracking number? (Yes / No) If yes, please provide: _______________________________________
Will this project require a filing with the Conservation Commission and/or DEP pursuant to the Wetlands Protection Act
(WPA)? (Yes / No) THIS FILING IS TO DETERMINE ENFORCEMENT ACTION NEXT STEPS ( PER YARMOUTH
CONSERVATION COMM.)
Map
*Required: Enclose a map with the site location clearly marked and centered on the page.Landowner Info
*Are you the Record Owner3 of the property? (Yes / No) NO
*If No, are you a representative of the Record Owner or do you have permission from the Record Owner to submit this request
or filing?4 (Yes / No) YES
*Landowner Name
*Street Address/Location *City/Town *State *Zip Code
Email Telephone
Comments/Purpose of request5: _________________________________________________________________________________
____________________________________________________________________________________________________________
1 Please disclose the full acreage of disturbance associated with the project, including areas outside of Priority Habitat.
2 If your project contains more than one registered property, please attach a document listing the Registry information for each.
3 Record Owner means any person or entity holding a legal or equitable interest, right or title to real property, as reflected in a written instrument or recorded deed,
or any person authorized in writing by such person.
4 If you are not the record owner, a statement or proof that you are authorized by the record owner must be attached.
5 Provide the authorization you have to submit this request if you are not the record owner and not a representative of the record owner.
v.5/2022
Applicant Info
Applicant Name (if different from Landowner)
Street Address/Location City/Town State Zip Code
Email (if available) Telephone
Representative Info
Applicant Name (if different from Landowner)
Street Address/Location City/Town State Zip Code
Email (if available) Telephone
*Required Documents
USGS map (1:24,000 or 1:25,000) with property boundary clearly outlined
Project plans for entire site (including wetland Resource Areas, showing existing and proposed conditions, existing and
proposed tree/vegetation clearing line, and clearly demarcated limits of work)
Assessor’s map or right-of-way plan of site
Statement/proof that applicant is the Record Owner or that applicant is a person authorized in writing by the record owner
to submit this filing
Photographs representative of the site
Projects altering 10 or more acres, must also submit:
A vegetation cover type map of the site Project plans showing Priority Habitat boundaries
The Division will notify you within 30 days if the materials submitted do not satisfy the filing requirements under 321 CMR 10.20.
The Division may request additional information, such as, but not limited to, species and habitat surveys. A request for additional
information would come within 30 days of receiving a complete filing.
*Filing Fee
Fee schedule is available at https://www.mass.gov/how-to/how-to-file-for-a-mesa-project-review
*Total MESA Fee Enclosed: ___________ Payable via check to Comm. of MA - NHESP
*Required Signatures
I hereby certify under the pains and penalties of perjury that the information contained is true and complete to the best of my
knowledge.
Signature of Property Owner/Record Owner of Property Date
Signature of Applicant (if different from Owner) Date
Please mail this completed form, with the required document and fee to:
NHESP Regulatory Review | MassWildlife Field Headquarters | 1 Rabbit Hill Road | Westborough, MA 01581
FIGURE 1 – PHOTO LOCATIONS , 1 THRU 4, GREAT ISLAND ROAD CAUSEWAY, NEAR WHITE CEDAR RD.
INTERSECTION 123 4
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