HomeMy WebLinkAboutNOI Signature page-ter
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Mas achusetts Deparbn nt of Environmental Pry
Bureau of Resource Protection —Wetlands Program
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Wction
of Intent
Restoration
G. Signatures and Submittal Requirements
Certificabon of Ecological Restoration Project Notice of Intent
MassDEP File Number
Yamnouth
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City or Taws
hereby certify under penalties o perjury that th cological Restoration Project Notice of I
ntent
application meets the EIIglbility Criteria set forhIn 310 CMR 10ml3aI also cerMy that I am
ftmiliar w,ith the information contained in this Notice of Intent application and that the accompanying
plans, documents, and supporting data are to the best of my knowledge and belief true, complete,
and accurate. I further certifythat I possess the authority to undertake the proposed activities..
understand that the Conservation Commission will place notification of this Notice in a focal
newsDaner at the expense of the applicant in accordance with the wetlands regulabons, 310 CMR
10.05(Rita).
further certify under penalties of perjury that all abutters were notified of this application, pursuant to
the requirements of M.G.L. c. 131 § 40. Notice must be made by Certificate of Mailing or in writing by
hand delivery or certified mail (return receipt requested) to all abutters within 100 feet of the property
line of the Droiect location.
6
1. Signature of Applicant or Authorized Agent
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2. Printed Name of Applicant or Authorized Agent 3,. date /
4. Signature of Property Owner (if different) _
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6,tStgnature o
epresen e (if any)
Cti,div
5. Date
7. Date
The certification must be signed by the applicant; however, it may be signed by a duly authorized
agent (named in Item 6) if this form is accompanied by a statement by the applicant designating the
agent and agreeing to furnish upon request, supplemental information in support of the application
For Conservation Commission:
Two copies of the completed Notice o ntent (Form 3), including supporting plans and documents,
finro copies of the N01 Wetland Fee Transmittal For and the city/town fee payment, to the
Conservation Commission by certified mail or hand delivery.
For MassDEP:
One copy of the completed Notice of Intent For 3), including supporting plans and documents, c,ne
copy of the N01 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:
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,,
wpafo 3a.doc • 2/8/2p1g
A Form 3A — NOI for Ecological Restoration Project •Page 13 of 20