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64-369 - 137 MARLBOROUGH ROAD - CONSERVATION COMMISSION /W�— ,JC)Nn lamS�,il 6�l- L,'36q f�� Vn�lydr�h � - ,�,,a r 0 CITY OF SALEM CONSERVATION COMMISSION STTF VTSTT FORM PROJECT LOCATION: � DATE OF SITE VISIT.--y�� PROJECT PROPONENT: I DEP FILE NUMBER: PROPOSED WORK: "A In _�W1� JOD �INATTENpANfE` !g!nt Commission Members/ Abutters: Applicant/Property Owner/Representative: ❑Request for Determination ❑Abbreviated Notice of Resource Area Delineation ❑Notice of Intent certificate of Compliance ❑Enforcement/Violation ❑Emergency ❑ Informal A�REAS.OF,7URI�4?ICTION: INLAND RESOURCE AREAS COASTAL RESOURCE AREAS ❑BankM ❑ Land Subject to Coastal ❑Land Under the Ocean Storm Flowage ❑Bordering Vegetated Wetland ❑IE Designated Port Area ❑Coastal Beach ❑Land Subject to Flooding $� ❑ Coastal Dune El Barrier Beach ❑Land Under Water Bodies or Waterway I Name: ! ❑ Coastal Bank ❑Rocky Intertidal Shore ❑Riverfront Area [j ❑ Salt Marsh ❑ Land Under Salt Pond ❑Vernal Pools ❑ Land Containing ❑Anadromous/Cata- Shellfish dromous Fish Run ElBordering Vegetated Wetland in Coastal Area 120 WASHINGTON .STREET, SALEM, MASSACHUSETTS 01970 •TEL: 978.745.9595 FAx: 978.740.0404 ♦ WWW.SALEM.COM J :BUFFERZONE�(rvi#Mn 100 f" ; '' � � � ❑Water Body ordering Vegetated Welland ❑ Bank ❑ Coastal Beach ❑Coastal Dune :INTERESS.EROTECTED a " . , Protection of Water Supply Protection of Groundwater Supply ,Flood Control "19 rm Damage Prevention Prevention of Pollution ❑Protection of Fisheries protection of Wildlife Habitat ❑Protection of Land Containing Shellfish Is this an exempt project: If so,why? Are resource area boundaries delineated correctly? If not,explain. �STt`E-VISI'G:D000MENTATiON ❑Photos ❑ Site Map ❑Other: Take into account relevant aspects or features such as: natural or piped drainage or obvious pollution; topography; existing vegetation; possible alternative sites; signs of wildlife, possible vernal pools, rare species habitat; landmarks; recent or historical disturbances; proximity to other water bodies or drainage areas; adjacent land uses. //� /� TO — ']A- Ui �9YD 1 `i"(P W1 w1 nis oo II`I riv a ��C t RECOMMENDATIONS_ �� CITY OF SALEM " CONSERVATION COMMISSION April 18, 2007 John Forristall 137 Marlborough Road Salem, MA 01970 Re: Certificate of Compliance—DEP #64-369-137 Marlborough Road, Salem, MA Dear Mr. Forristall: Enclosed, please find the Certificate of Compliance for the above referenced project. This Document must be recorded at the Essex County Registry of Deeds, 36 Federal Street Salem, Massachusetts. Please fill out and return the Recording Information on page 4 of the Certificate of Compliance, which will indicate to the Salem Conservation Commission that the document has been recorded. If you have any further questions please feel free to contact me at (978) 619-5685. Since IA.t/v Carey Duques Conservation Agent/ Staff Planner Enclosures CC: DEP Northeast Regional Office Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands DEP File Number: WPA Form 86 — Certificate of Compliance 64-369 Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Provided by DEP A. Project Information Important: When filling out 1. This Certificate of Compliance is issued to: forms on the John J. Forristall computer, use Name only the tab key to move 137 Marlborough Road your cursor- Mailing Address do not use the Salem MA 01970 return key. City/Town State Zip Code VQ 2. This Certificate of Compliance is issued for work regulated by a final Order of Conditions issued to: John Forristall Name June 11, 2004 64-369 Dated DEP File Number 3. The project site is located at: 137 Marlborough Road Salem Street Address City/Town Map 9 Lot 276 Assessors Map/Plat Number Parcel/Lot Number the final Order of Condition was recorded at the Registry of Deeds for: Property Owner(if different) Essex 23019 99 County Book Page Certificate 4. A site inspection was made in the presence of the applicant, or the applicant's agent, on: April 10, 2007 Date B. Certification Check all that apply: Complete Certification: It is hereby certified that the work regulated by the above-referenced Order of Conditions has been satisfactorily completed. (] Partial Certification: It is hereby certified that only the following portions of work regulated by the above-referenced Order of Conditions have been satisfactorily completed.The project areas or work subject to this partial certification that have been completed and are released from this Order are: w aform 8b.doc•rev.7113/00 Page 1 of 4 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands DEP File Number: WPA Form 8B — Certificate of Compliance 64-369 Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Provided by DEP B. Certification (cont.) ❑ Invalid Order of Conditions: It is hereby certified that the work regulated by the above-referenced Order of Conditions never commenced.The Order of Conditions has lapsed and is therefore no longer valid. No future work subject to regulation under the Wetlands Protection Act may commence without filing a new Notice of Intent and receiving a new Order of Conditions. ❑ Ongoing Conditions: The following conditions of the Order shall continue: (Include any conditions contained in the Final Order, such as maintenance or monitoring, that should continue for a longer period). Condition Numbers: C. Authorization Issued by: Salem Conservation Commission Da of Issuance This Certificate must be si ned by a majority of the Conservation Commission and a copy sent to the applicant and ap to, I e D R inal Office ( ee Attachment). Signatures: Q wpaform Boom•rev,7113104 Page 2 of 4 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands DEP File Number. WPA Form 8B — Certificate of Compliance 64-369 Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Provided by DEP C. Authorization (cont.) Notary Acknowledgement Commonwealth of Massachusetts County of Essex On this 12 April 2007 Day Of Month Year before me, the undersigned Notary Public, personally appeared K. Cornacchio, D. Pabich, D. Summer, and A. Hamilton, Name of Document Signer proved to me through satisfactory evidence of identification, which was/were personally known Description of evidence of identification to be the person whose name is signed on the preceding or attached document, and acknowledged to me that he/she signed it voluntarily for its stated purpose. As member of Salem City/TownConservation Commission I$ CAREY R.DUOUEi �H ap KULMWjKM hh Cemniedm eon AuMN 1E,2013 f Signature of otary Public Care R. u ues Printed Name of Notary Public August 16, 2013 My Commission Expires(Date) Place notary seal and/or any stamp above Signature of Notary Public wpaform 8b.tloc•rev.7/13/04 Page 3 of 4 i Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands DEP File Number: WPA Form 813 — Certificate of Compliance 64-369 Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Provided by DEP D. Recording Confirmation The applicant is responsible for ensuring that this Certificate of Compliance is recorded in the Registry of Deeds or the Land Court for the district in which the land is located. Detach on dotted line and submit to the Conservation Commission. -------------------------------------------------------------------------------------------------------------------------- To: Salem Conservation Commission Please be advised that the Certificate of Compliance for the project at: 137 Marlborough Road 64-369 Project Location DEP File Number Has been recorded at the Registry of Deeds of: County for: Property Owner and has been noted in the chain of title of the affected property on: e Book Page 9 If recorded land, the instrument number which identifies this transaction is: If registered land, the document number which identifies this transaction is: Document Number Signature of Applicant wpatorm 8b.doc•rev.7113/D4 Page 4 of 4 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands DEP Regional Addresses Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Mail transmittal forms and DEP payments,payable to: Commonwealth of Massachusetts Department of Environmental Protection Box 4062 Boston, MA 02211 DEP Western Region Adam Colrain Hampden Monroe Pittsfield Tyringham 436 Dwight Street Agawam Conway Hancock Montague Plainfield Wales Micro Cummington Hatfield Monterey Richmond Ware Spite 402 Amherst Dalton Hawley Montgomery Rowe Warwick Springfield,MA 01103 Ashfiald Deerfield Heath Monson Russell Washington Phone:413-784-1100 Becket Easthampton Hinsdale Mount Washington Sandisfielo Wendell Belchartown East Longmadow Holland New Ashford Savoy Westfield Fax:413-784-1149 Bemardston Egremont Holyoke New Marlborough Sheffield Westhampton Blandford Erving Huntington New Salem Shelburne West Springfield Brimfield Florida Lanesborough North Adam Shutasbury West Stmkbddge Buckland Gill Lee Northampton Southampton Whately Chartemont Goshen Lenox Northfield South Hadley Wilbraham Cheshire Granby Leveratt Orange Southwick Williarmburg Chaster Granville Leyden Otis Springfield Williarmtown Chesterfield Great Barrington Longmeadow Palrmr Stockbridge Windsor Chicopee Greenfield Ludlow Pelham Sunderland Worthington Clarksburg Hadley Middlefield Peru Tolland DEP Central Region Anon Chariton Hopkinton Millbury Rutland Uxbridge 627 Main Street Ashbumham Clinton Hubbardston Millville Shirley Warren Ashby Douglas Hudson New Braintree Shrewsbury Webster Worcester,MA 01608 Athol Dudley Holliston Npdhborough Southborough Westborough Phone:508-792-7650 Auburn Dunstable Lancaster Northbridge Southbridge west Boylston Fax:508-792-7621 Ayer East Brookfield Leicester North Brookfield spencer West Brookfield Barre Fitchburg Leominster Oakham Sterling Westford TDD:508-767-2788 Bellingham Gardner Littleton Oxford Stow Westmnster Berlin Grafton Lunenburg Paxton Sturbridge Winchendon Blackstone Groton Marlborough Pepperell Sutton Worcester Bolton Harvard Maynard Petersham Templeton Bo>aorough Hardwick Medway Phillipston Townsend Boylston Holden Mendon Princeton - Tyngsborough Brookfield Hopedale Milford Royalston Upton DEP Southeast Region Abington Dartmouth Freetown Mattapoisem Provincetown Tisbury 20 Riverside Drive Acushnet Dennis Gay Head Middleborough Raynham Truro Attleboro Dighton Gosnold Nantucket Rehoboth Wareham Lakeville,MA 02347 Avon Duxbury Halifax New Bedford Rochester Wellfieet Phone:508-946-2700 Barnstable Eastham Hanover North Atlleborough Rockland Wast Bridgewater Fax:508-947-6557 Berkley East Bridgewater Hanson Norton Sandwich Westport Bourne Easton Harwich Norwell Scituate West rsbury TDD:508-946-2795 Brewster Edgartown Kngston Oak Bluffs Seekonk Whitman Bridgewater Fairhaven Lakeville Greens Sharon Wrentham Brockton Fall River Mansfield Pembroke Somerset Yarmouth Carver Falmouth Marian Plainville Stoughton Chatham Foxborough Marshfield Plymouth Swansea Chilmark Franoin Mashpee Plymptan Taunton DEP Northeast Region Amesbury Chelmsford Hingham Meminac Quincy Wakefield 1 Winter Street Andover Chelsea Holbrook Methuen Randolph welpole Arlington Cohasset Hull Middleton Reading Waltham Boston, MA 02108 Ashland Concord 1pswch Millis Revere Watertown Phone:617-654-6500 Bedford Danvers Lawrence Milton Rockport Wayland Fax: 617-556-1049 Belmont Dedham Leengton Nahant Rowley Wellesley Beverly Dover Lincoln Natick Salem Wenham TDD:617-574-6868 Billerica Dracut Lowell Needham Salisbury West Newbury Boston Essex Lynn Newbury Saugus Weston Boxford Everett Lynnfield Newburyport Sherbom Wesiwo k! Braintree Frarringham Maiden Newton Somerville Weymouth Brookline Georgetown Manchester By.The-Sea Norfolk Stoneham Wilmington Burlington Gloucester Marblehead North Andover Sudbury Winchester Camondge Ghweland Medfield North Reading Swampscott Winthrop Canton Hamilton Medford Norwood Tewksbury Woburn Cadisle Haverhill Melrose Peabody TopsfieW wpaform8b.doc•DEP Addresses•rev.4/18/07 Page 1 of 1 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands DEP File Number: WPA Form 8A — Request for Certificate of Compliance Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Provide-by DEP A. Project Information Important: MAR 2 12007 When filling out t• This request is being made by: forms on the I_ DEFT.OF PLANNING$ computer, use �t'`r -� E® r r i s rF� L I COD PT.OF PLANNING & only the tab Name `� key to move i 3 / �k A,r I bo r<) a , your cursor- Mailing Address do not use the I return key. CityiTocwn� 'I &' 014Zb 710 " 6`7� I State Zip Code � Phone Number 2. This request is in reference to work regulated by a final Order of Conditions issued to: -To- L. rc...r-15N14ct Applicant Dated /opt Coyl -03Ce9 Upon completion DEP file Number of the work 3. The project site is located at: authorized in 139 3 v� � an Order of ((i7c74_> N A9L Ca . 'A Conditions, the Street Address Cr Gty/I own property owner 1 0 a "'I � must request a Assessors Map/Plat Number Certificate of Parcel/Lot Number Compliance 4. The final Order of Conditions was recorded at the Registry of Deeds for: from the issuing authority stating Property Owner(if different) that the work or portion of the E5S i= X q work has been County satisfactorily Book Pag---e-°-- completed. Certificate(if registered land) 5. This request is for certification that (check one): ® the work regulated by the above-referenced Order of Conditions has been satisfactorily completed. th e following ❑ win portions g p rtlons of the work regulated by the above-referenced Order of Conditions have been satisfactorily completed (use additional paper if necessary). ❑ the above-referenced Order of Conditions has lapsed and is therefore no longer valid, and the work regulated by it was never started. ,,alorm9a.tloc•rev.7/1Hr04 Page 1 of r Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands DEP File Number: WPA Form 8A — Request for Certificate of Compliance Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Provided by DEP A. Project Information (cont.) 6. Did the Order of Conditions for this project, or the portion of the project subject to this request, contain an approval of any plans stamped by a registered professional engineer, architect, landscape architect, or land surveyor? ® Yes If yes, attach a written statement by such a professional certifying substantial compliance with the plans and describing what deviation, if any, exists from the plans approved in the Order. ❑ No B. Submittal Requirements Requests for Certificates of Compliance should be directed to the issuing authority that issued the final Order of Conditions (OOC). If the project received an OOC from the Conservation Commission, submit this request to that Commission. If the project was issued a Superseding Order of Conditions or was the subject of an Adjudicatory Hearing Final Decision, submit this request to the appropriate DEP Regional Office (see Attachment). "aform8a.doo•rev.7/13/04 Pape 2 of 2 rr Massachusetts Department of-Environmental Protection Bureau of Resource Protection - Wetlands DEP Regional Addresses Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Mail transmittal forms and DEP payments,payable to: Commonwealth of Massachusetts Department of Environmental Protection Box 4062 Boston, MA 02211 DEP Western Region Adam Colrain Hampden Monroe Pittsfield Tyringham 436 Dwight Street Agawam Conway Hancock Montague Plainfield Wales Atom Cummington Hatfield Monterey Richmond Were Suite 402 Amherst Dalton Hawley Montgomery Rows Warwick Springfield,MA 01103 Ashfield Deerfield Heath Monson Russell Washington Phone:413-784-1100 Becket Easthampton Hinsdale Mount Washington Sandisfield Wardell Belchertown East Longmeadow Holland New Ashford Savoy Westtield Fax:413-784-1149 Bemardston Egramont Holyoke New Marlborough Sheffield Westhampton Slandfora Erving Huntington New Salem Shelburne West Springfield Brimfield Florida Lanesborough North Adam SholeSbury West Stockbridge Buckland Gill Lee Northampton Southampton Whately Chaderront Goshen Lenox Northfield South Hadley Wilbraham Cheshire Granby Leveralt Orange Southwick Williansburg Chester Grenville Leytlen Otis Springfield Williamstown Chefoameld Great Barrington Longmeadow Painter Stockbridge Windsor Chicopee Greenfield Ludlow Pelham Sunderland Worthington Clarksburg Hadley Middlefield Pam Tolland DEP Central Region Anon ChaMon Hopkinton Millbury Rutland Uxbndge 627 Main Street Ashbumham Clinton Hubbardston Millville Shmey Warren Ashby Douglas Hudson New Braintree Shrewsbury Webster Worcester, MA 01608 Athol Dudley Holliston Northborough Southborough Westborough Phone:508-792-7650 Album Dunstable Lancaster Northbridge Southbridge West Boylston Fax:508-792-7621 Ayer East Brookfield Leicester North Brookfield Spencer West Brockfield Bame Fitchburg Leominster Oakham Sterling Westford TDD:508-767-2788 Bellingham Gardner Littleton Oxford Stow Westminster Berlin Grafton Lunenburg Pacton Sturbridge Winchendon Blackstone Groton Marlborough Pepperell Sutton Worcester Bolton Harvard Maynard Petersham Templeton Boxborough Hardwick Medway Phillipston Townsend Boylston Holden Mention Princeton Tyngsdorough Brookfield Hopedale Milford Royalston Upton DEP Southeast Region Abington Dartmouth Freetown Maltapoisetl Provincetown Tsbury 20 Riverside Drive Acushnet Dennis Gay Head Middleborough Raynham Truro Attleboro Dighton Gosncid Nantucket Rehoboth Wareham Lakeville,MA 02347 Avon Duxbury Halifax New Bedford Rochester Wellfleet Phone: 508-946-2700 Barnstable Eastham Hanover North Attleborough Rockland West Bridgewater Fax:508-947-6557 Berkley East Bridgewater Hanson Norton Sandwich Wastpon Bourne Easton Harwich Norwell Scituate West Tsbury, TDD:508-946-2795 Brewster Edgartown Kingston Oak Bluffs Seekonk Whitman Bridgewater Fairhaven Lakeville Orleans Sharon Wrentham Brockton Fall River Mansfield Pembroke Somerset yamwuth Carver Falmouth Marion Plainville Stoughton Chatham Foxborough Marshfield Plymouth Swansea Chilmark Franklin Mashpee Plyrrpton Taunton DEP Northeast Region Amesbury Chelmsford Hingham Merrimac Ouincy Wakefield 1 Winter Street Andover Chelsea Holbrook Methuen Randolph Walpole Mington Cohasset Hull Middleton Reading Waltham Boston,MA 02108 Ashland Concord fpswich Millis Revere Watertown Phone:617-654-6500 Bedford Danvers Lawrence Mifton Rockport Wayland Fax: 617-556-1049 Belmont Dedham Lexington Nahant Rowley Wellesley Bevedy Dover Lncdn Natick Salem Wenham TDD: 617-574-6868 Billerica Dracut Lowell Needham Salisbury West Newbury Boston Essex Lynn Newbury Saugus Weston Sox ord Everett Lyn afield Newburyport Sherbom Westwood Braintree Framingham Malden Newton Somerville Weymouth Brookline Georgetown Manchester-By-The-Sea Norfolk Stoneham Wilmington Burlington Gloucester Marblehead North Andover Sudbury Winchester Cambridge Grovdand Mactiold North Reading Swampscott Winthrop Canton Hamilton Method Norwood Tewksbury Woburn Cadlsle Haverhill Melrose Peabody Tcpsfieud wpaforinsa.doc•DEP Addresses•rev.V13/04 Page 1 of 1 0 CITY OF SALEM CONSERVATION COMMISSION March 15, 2007 John Forristall 137 Marlborough Road Salem, Massachusetts 01970 Re: DEP #64-369—Installation of an in-ground pool-137 Marlborough Road, Salem, Massachusetts Dear Mr. Forristall: Please be advised that the Order of Conditions for the above referenced project will expire on May 27, 2007. If this development project is complete,you should Request a Certificate of Compliance (enclosed forms) from the Salem Conservation Commission. If this development project has not been completed, than you must submit a written request for an extension of the existing Order of Conditions to the Commission at least 30-days prior to the expiration of the order, as required in the Wetland Protection Act. If the project has not been completed and your Order of Conditions expires, you will be required to file a new Notice of Intent to complete this previously approved project. Please contact me at (978) 619-5685 if you have any questions. Sincerely, Carey Duques Conservation Agent/Planner Enclosures 120 WASHINGTON STREET, SALEM, MASSACHUSETTS 01970 . TEL: 978.745.9595 FAx: 978.740.0404 WWW.SALEM.COM VW AMR Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands DEP File Number: WPA Form 5 — Order of Conditions 64-0369 Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 A. General Information Important: SALEM When filling From: t.Conservation Commission out forms on the computer, 2.This issuance is for(check one): ® Order of Conditions ❑ Amended Order of Conditions use only the tab key to 3. To: Applicant: move your cursor-do not John Forristall use the return a. First Name b.Last Name c.Company key.�InI 137 Marlborough Road —I��I d.Mailing Address k b1 Salem Me 01970 e.City/Town f.State g.Zip Code mm 4. Property Owner(if different from applicant): Same a.First Name b. Last Name c.Company d.Mailing Address e.Cityfrown f.State g.Zip Code 5. Project Location: 137 Marlborough Road Salem a.Street Address b.City/Town 9 0276 c.Assessors Map/Plat Number d.Parcel/Lot Number Latitude and Longitude, if known (note: electronic filers will click for GIS locator): e.Latitude f.Longitude 6. Property recorded at the Registry of Deeds for(attach additional information if more than one parcel): Essex a.County b.Certificate(if registered land) 17193 455 c. Book d.Page 7. Dates: May 12, 2004 June 11, 2004 June 11, 2004 a.Date Notice of Intent Filed b. Date Public Hearing Closed c.Date of Issuance a. Final Approved Plans and Other Documents (attach additional plan or document references as needed): Plot Plan of Land a. Plan Title Bay State Surveying Assoc. Inc. Robert James Sotiros b.Prepared By c.Signed and Stamped by 1" =40' d. Final Revision Date e.Scale I.Additional Plan or Document Title g.Date $55 $15 $40 s. Total WPA Fee Paid: a.Total Fee Paid b.State Fee Paid c.Cityrrown Fee Paid wpat"S.doc• rev.6H4/D4 Page 1 of e Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands DEP File Number: WPA Form 5 - Order of Conditions 64-0369 Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 B. Findings 1. Findings pursuant to the Massachusetts Wetlands Protection Act: Following the review of the above-referenced Notice of Intent and based on the information provided in this application and presented at the public hearing, this Commission finds that the areas in which work is proposed is significant to the following interests of the Wetlands Protection Act. Check all that apply: a. ❑ Public Water Supply b. ❑ Land Containing Shellfish c. ❑ Prevention of Pollution d. ❑ Private Water Supply e. ❑ Fisheries f. ❑ Protection of Wildlife Habitat g. ❑ Groundwater Supply h. ❑ Storm Damage Prevention I. ® Flood Control 2. This Commission hereby finds the project,as proposed, is:(check one of the following boxes) Approved subject to: ® the following conditions which are necessary in accordance with the performance standards set forth in the wetlands regulations. This Commission orders that all work shall be performed in accordance with the Notice of Intent referenced above, the following General Conditions, and any other special conditions attached to this Order. To the extent that the following conditions modify or differ from the plans, specifications, or other proposals submitted with the Notice of Intent, these conditions shall control. Denied because: ❑ the proposed work cannot be conditioned to meet the performance standards set forth in the wetland regulations. Therefore, work on this project may not go forward unless and until a new Notice of Intent is submitted which provides measures which are adequate to protect these interests, and a final Order of Conditions is issued. A description of the performance standards which the proposed work cannot meet is attached to this Order. ❑ the information submitted by the applicant is not sufficient to describe the site, the work, or the effect of the work on the interests identified in the Wetlands Protection Act. Therefore, work on this project may not go forward unless and until a revised Notice of Intent is submitted which provides sufficient information and includes measures which are adequate to protect the Act's interests, and a final Order of Conditions is issued.A description of the specific information which is lacking and why it is necessary is attached to this Order as per 310 CMR 10.05(6)(c). Inland Resource Area Impacts: Check all that apply below. (For Approvals Only) Resource Area Proposed Permitted Proposed Permitted Alteration Alteration Replacement Replacement 3. ❑ Bank a.linear feet b.linear feet c.linear feet d.linear feet 4. ❑ Bordering Vegetated Wetland a.square feet b.square feet c.square feet d.square feet 5. ❑ Land Under a.square feet b.square feet c.square feet d.square feet Waterbodies and Waterways e.cu.yd dredged f,cu.yd dredged wpafor 5.dw• rev.6/14104 Page 2 of 8 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands DEP File Number: WPA Form 5 - Order of Conditions 64-0369 Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 B. Findings (cont.) Resource Area Proposed Permitted Proposed Permitted Alteration Alteration Replacement Replacement 6. ❑ Bordering Land Subject to Flooding a.square feet b.square feet c.square feet d.square feet Cubic Feet Flood Storage e.cubic feet f.cubic feet g.cubic feet h.cubic feet 7. ❑ Isolated Land Subject to Flooding a.square feet b.square feet Cubic Feet Flood Storage c.cubic feet d.cubic feet e.cubic feet I.cubic feet 8. ❑ Riverfront area a.total sq.feet b.total sq.feet Sq ft within 100 ft c.square feet d.square feet Sq ft between 100-200 ft e.square feet f.square feet Coastal Resource Area Impacts: Check all that apply below. (For Approvals Only) s. ❑ Designated Port Areas Indicate size under Land Under the Ocean, below to. ❑ Land Under the Ocean a.square feet b.square feet c.cu.yd dredged d.cu.yd dredged 11. ❑ Barrier Beaches Indicate size under Coastal Beaches and/or Coastal Dunes below 12. ❑ Coastal Beaches a.square feet b,square feet c.cly nourishmt. d.dy nourishmt. 13. ❑ Coastal Dunes a.square feet b.square feet c.dy nourishmt. d.c/y nourishmt 14. ❑ Coastal Banks a.linear feet b.linear feet 15. ❑ Rocky Intertidal Shores a.square feet b.square feet 16. ❑ Salt Marshes a.square feet b.square feet c.square feet d.square feet 17. ❑ Land Under Salt Ponds a.square feet b.square feet c.cu.yd dredged d.cu.yd dredged 18. ❑ Land Containing Shellfish a.square feet b.square feet c.square feet d.square feet 19. ❑ Fish Runs Indicate size under Coastal Banks, inland Bank, Land Under the Ocean, and/or inland Land Under Waterbodies and Waterways, above a.cu.yd dredged b.ou yd dredged 20. ❑ Land Subject to Coastal Storm Flowage a.square feet b.square feet wpafom5.doc• rev.6114/04 Page 3 of 8 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands DEP File Number: WPA Form 5 - Order of Conditions 64-0369 Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 C. General Conditions Under Massachusetts Wetlands Protection Act (only applicable to approved projects) 1. Failure to comply with all conditions stated herein, and with all related statutes and other regulatory measures, shall be deemed cause to revoke or modify this Order. 2. The Order does not grant any property rights or any exclusive privileges; it does not authorize any injury to private property or invasion of private rights. 3. This Order does not relieve the permittee or any other person of the necessity of complying with all other applicable federal, state, or local statutes, ordinances, bylaws, or regulations. 4. The work authorized hereunder shall be completed within three years from the date of this Order unless either of the following apply: a. the work is a maintenance dredging project as provided for in the Act; or b. the time for completion has been extended to a specified date more than three years, but less than five years, from the date of issuance. If this Order is intended to be valid for more than three years, the extension date and the special circumstances warranting the extended time period are set forth as a special condition in this Order. 5. This Order may be extended by the issuing authority for one or more periods of up to three years each upon application to the issuing authority at least 30 days prior to the expiration date of the Order. 6. Any fill used in connection with this project shall be clean fill. Any fill shall contain no trash, refuse, rubbish, or debris, including but not limited to lumber, bricks, plaster, wire, lath, paper, cardboard, pipe, tires, ashes, refrigerators, motor vehicles, or parts of any of the foregoing. 7. This Order is not final until all administrative appeal periods from this Order have elapsed, or if such an appeal has been taken, until all proceedings before the Department have been completed. 8. No work shall be undertaken until the Order has become final and then has been recorded in the Registry of Deeds or the Land Court for the district in which the land is located, within the chain of title of the affected property. In the case of recorded land, the Final Order shall also be noted in the Registry's Grantor Index under the name of the owner of the land upon which the proposed work is to be done. In the case of the registered land, the Final Order shall also be noted on the Land Court Certificate of Title of the owner of the land upon which the proposed work is done. The recording information shall be submitted to this Conservation Commission on the form at the end of this Order, which form must be stamped by the Registry of Deeds, prior to the commencement of work. 9. A sign shall be displayed at the site not less then two square feet or more than three square feet in size bearing the words, "Massachusetts Department of Environmental Protection" (or, "MA DEP'J "File Number 64-0369 " wpafo=5.doc• rev.6114104 Pape 4 of 8 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands DEP File Number: WPA Form 5 - Order of Conditions 64-0369 Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 C. General Conditions Under Massachusetts Wetlands Protection Act 10. Where the Department of Environmental Protection is requested to issue a Superseding Order, the Conservation Commission shall be a party to all agency proceedings and hearings before DEP. 11. Upon completion of the work described herein, the applicant shall submit a Request for Certificate of Compliance (WPA Form 8A)to the Conservation Commission. 12. The work shall conform to the plans and special conditions referenced in this order. 13. Any change to the plans identified in Condition#12 above shall require the applicant to inquire of the Conservation Commission in writing whether the change is significant enough to require the filing of a new Notice of Intent. 14. The Agent or members of the Conservation Commission and the Department of Environmental Protection shall have the right to enter and inspect the area subject to this Order at reasonable hours to evaluate compliance with the conditions stated in this Order, and may require the submittal of any data deemed necessary by the Conservation Commission or Department for that evaluation. 15. This Order of Conditions shall apply to any successor in interest or successor in control of the property subject to this Order and to any contractor or other person performing work conditioned by this Order. 16. Prior to the start of work, and if the project involves work adjacent to a Bordering Vegetated Wetland, the boundary of the wetland in the vicinity of the proposed work area shall be marked by wooden stakes or flagging. Once in place, the wetland boundary markers shall be maintained until a Certificate of Compliance has been issued by the Conservation Commission. 17. All sedimentation barriers shall be maintained in good repair until all disturbed areas have been fully stabilized with vegetation or other means.At no time shall sediments be deposited in a wetland or water body. During construction, the applicant or his/her designee shall inspect the erosion controls on a daily basis and shall remove accumulated sediments as needed. The applicant shall immediately control any erosion problems that occur at the site and shall also immediately notify the Conservation Commission, which reserves the right to require additional erosion and/or damage prevention controls it may deem necessary. Sedimentation barriers shall serve as the limit of work unless another limit of work line has been approved by this Order. Special Conditions: If you need more See Attached Sheet space for additional conditions, select box to attach a text document ❑ wpaform5.doc• rev.6/14104 Page 5 of 8 Massachusetts Department of Environmental Protection DEP File Number: Uf Bureau of Resource Protection -WetlandsI) -69WPA Form 5 - Order of Conditions Provided byMassachusetts Wetlands Protection Act M.G.L. c. 131, §40 B. Findings (cont.) Additional conditions relating to municipal ordinance or bylaw: This Order is valid for three years, unless otherwise specified as a special condition pursuant to General Conditions#4, from the date of issuance. Date This Order must be signed by a majority of the Conservation Commission. The Order must be mailed by certified mail (return receipt requested)or hand delivered to the applicant. A copy also must be mailed or hand delivered at the same time to the appropriate Department of Environmental Protection Regional Office (see Appendi A) and the property owner(if diffe ent from a plicant) Signatures: , ,J,L, On e IeVent-A Of Day Month and Year before me personally appeared R 5ov1-(_ to me known to be theperson described in and who executed the foregoing instrument and acknowle d t a he/ execut t e same as his/her free act and deed. ...e Et.l..frf M Commission Expires me - h Notary is Y P' My Comm�ss:cn Expires - i November t,2087 This Order is issued to the applicant as follows: ❑ by hand delivery on by certified mail, return receipt requested, on _ b Date - Date WPA Farm 5 Page 5 of 7 Rev.02/00 Massachusetts Department of Environmental Protection DEP File Number: r Bureau of Resource Protection - Wetlands 6q -036 WPA Form 5 - Order of Conditions Provided by DEP w. ' Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 C. Appeals The applicant, the owner, any person aggrieved by this Order, any owner of land abutting the land subject to this Order, or any ten residents of the city or town in which such land is located, are hereby notified of their right to request the appropriate DEP Regional Office to issue a Superseding Order of Conditions. The request must be made by certified mail or hand delivery to the Department, with the appropriate filing fee and a completed Appendix E: Request of Departmental Action Fee Transmittal Form, as provided in 310 CMR 10.03(7)within ten business days from the date of issuance of this Order. A copy of the request shall at the same time be sent by certified mail or hand delivery to the Conservation Commission and to the applicant, if he/she is not the appellant. The request shall state clearly and concisely the objections to the Order which is being appealed and how the Order does not contribute to the protection of the interests identified in the Massachusetts Wetlands Protection Act, (M.G.L. c. 131, §40)and is inconsistent with the wetlands regulations (310 CMR 10.00). To the extent that the Order is based on a municipal ordinance or bylaw, and not on the Massachusetts Wetlands Protection Act or regulations, the Department has no appellate jurisdiction. D. Recording Information This Order of Conditions must be recorded in the Registry of Deeds or the Land Court for the district in which the land is located, within the chain of title of the affected property. In the case of recorded land, the Final Order shall also be noted in the Registry's Grantor Index under the name of the owner of the land subject to the Order. In the case of registered land, this Order shall also be noted on the Land Court Certificate of Title of the owner of the land subject to the Order of Conditions.The recording information on Page 7 of Form 5 shall be submitted to the Conservation Commission listed below. b lewi Conservation Commission WPA Farm 5 Page 6 of 7 Rev.Moo Massachusetts Department of Environmental Protection DEP File Number: Bureau of Resource Protection - Wetlands WPA Form 5 - Order of Conditions 64-0369 Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 G. Recording Information This Order of Conditions must be recorded in the Registry of Deeds or the Land Court for the district in which the land is located,within the chain of title of the affected property. In the case of recorded land, the Final Order shall also be noted in the Registry's Grantor Index under the name of the owner of the land subject to the Order. In the case of registered land, this Order shall also be noted on the Land Court Certificate of Title of the owner of the land subject to the Order of Conditions. The recording information on Page 7 of this form shall be submitted to the Conservation Commission listed below. SALEM Conservation Commission Detach on dotted line, have stamped by the Registry of Deeds and submit to the Conservation Commission. ----------------------------------------------------------------------------------------------------------------------- To: SALEM Conservation Commission Please be advised that the Order of Conditions for the Project at: 137 Marlborough Road 64-0369 Project Location DEP File Number Has been recorded at the Registry of Deeds of: County Book Page for: Property Owner and has been noted in the chain of title of the affected property in: Book Page In accordance with the Order of Conditions issued on: Date If recorded land, the instrument number identifying this transaction is: Instrument Number If registered land, the document number identifying this transaction is: Document Number Signature of Applicant wpafa m5.dm• rev.6/14/04 Page 8 of 8 Salem Conservation Commission SPECIAL CONDITIONS—DEP FILE # 64-0369 City of Salem, 137 Marlborough Road 1. The Conservation Agent will be notified 48 hours prior to commencement of construction activities(978-745- 9595 ext. 311). Members and agents of the Salem Conservation Commission(Commission)shall have the right to enter and inspect the premises to evaluate and ensure compliance with the conditions and performance standards stated in this Order,the Notice of Intent,the referenced plans,the Act, and 310 CMR 10.00,and may require any information,measurements,photographs, observation and/or materials or may require the submittal of any data or information deemed necessary by the Commission,agent,or DEP determines that any of the work is not in compliance with this Order of Conditions. Work shall not resume until the Commission is satisfied that the work will comply,and has so notified the applicant in writing. 2. Approval of this application does not constitute compliance with any law or regulation other than MGL Chapter 131, Section 40,and Wetlands Regulations 310 CMR 10.00. 3. This Order shall apply to any successor in control or successor in interest of the property described in the Notice of Intent and accompanying plans. These obligations shall be expressed in covenants in all deeds to succeeding owners or portions of the property. 4. The form provided at the end of this Order shall be completed and stamped at the Registry of Deeds after the expiration of the 10-day appeal period and within 30 days of the issuance if no request for appeal has been filed with the Department of Environmental Protection. This form shall be returned to the Commission within 21 days of recording accordance and prior to commencement of any activities subject to the Order of Conditions. 5. Prior to any work commencing,a sign shall be displayed showing DEP File#64-0369,and not placed on a living tree. 6. The term"Applicant"as used in this Order of Conditions shall refer to the owner, any successor in interest or successor in control of the property referenced in the Notice of Intent,supporting documents and this Order of Conditions. The Commission shall be notified in writing within 30 days of all transfers of title of any portion of the property that takes place prior to issuance of the Certificate of Compliance. 7. It is the responsibility of the applicant to procure all other applicable federal, state and local permits and approvals associated with this project. These permits may include but are not necessarily limited to the following: (1) Section 404 of the Federal Water Pollution Control Act(P.L. 92-500, 86 star. 816),U.S.Army Corp of Engineers. (2) Water Quality Certification in accordance with the Federal Water Pollution Control under authority of sec. 27(5)of Chapter 21 of the Massachusetts General Laws as codified (3) Flood Plain (4) Grading Ordinance 8. If there are conflicting conditions within this Order,the stricter condition(s)shall rule. 9. All work shall be performed so as to ensure that there will be no sedimentation into wetlands and surface waters during construction or after completion of the project. 10. The Commission and its Administrator shall have the discretion to modify the erosion/siltation control methods and boundary during construction if necessary. 11. All work shall be performed in accordance with this Order of Conditions and approved site plans(s). No alteration of wetland resource areas or associated buffer zone,other than that approved in this Order,shall occur on this property without prior approval from the Commission. 12. If any changes are made in the above-described plan(s)which may or will alter an area subject to protection under the Wetlands Protection Act,or any changes in activity subject to regulations under G.L.Ch. 131,Section 40,the applicant shall inquire from this Commission in writing,prior to their implementation in the field, whether the change(s)is significant enough to require the filing of a new Notice of Intent. Any error in the plans or information submitted by the applicant shall be considered changes and the above procedures shall be followed. A copy of such request shall at the same time be sent to the Department of Environmental Protection. 13. In conjunction with the sale of this property or any portion thereof before a Certificate of Compliance has been issued,the applicant or current landowner shall submit to the Commission a signed statement by the buyer that he/she is aware of an outstanding Order of Conditions on the property and has received a copy of the Order of Conditions. 14. Conditions number as indicated shall continue in force beyond the Certificate of Compliance,in perpetuity, and shall be referred to in all future deeds to this property. PRIOR TO CONSTRUCTION 15. Prior to commencement of any activity on this site,there shall be a PRECONSTRUCTION MEETING between the project supervision,the contractor responsible for the work or its administrator to and phone numbers of all responsible parties shall be registered with the Commission at the pre-construction meeting. 16. Prior to the pre-construction meeting and commencement of any activity on this site, sedimentation and erosion control barriers shall be installed as shown on the approval plan(s)and detail drawings. The Commssion and/or its Administrator shall inspect and approve such installation at the pre-construction meeting. 17. Prior to the commencement of any activity on this site,the applicant or current landowner shall submit to the Commission in writing a construction schedule/sequence of work to complete this project. 18. Prior to any work on site,the proposed limits of work shall be clearly marked with stakes or flags and shall be confirmed by the Commission or its Administrator. Such markers shall be checked and replaced as necessary and shall be maintained until all construction is complete. Workers shall be informed that no use of machinery, storage of machinery or materials,stockpiling of soil or construction activity is to occur beyond this line at anytime. 19. Prior to commencement of construction on site,the limits of wetland resource areas closest to construction activity shall be flagged with surveyor's tape and shall remain in place during construction. The limits of areas to be impacted and the limits of work in the replication area(a)shall be clearly flagged. 20. There shall be hay bales and wooden staked stored under cover on the site to be used only for emergency erosion control. EROSION CONTROL 21, Appropriate erosion control devices shall be in place prior to the beginning of any phases of construction,and shall be maintained during construction in the wetland areas and buffer zones. The erosion control specification provided in the Notice of Intent and the erosion control provision in the Order will be the minimum standards for this project;additional measures may be required by the Commission. 22. All debris, fill and excavated material shall be stockpiled a location far enough away from the wetland resource areas to prevent sediment from entering wetland resource areas. 23. Erosion and sedimentation control devices shall be inspected after each storm event and repaired or replaced as necessary. Any accumulated silt adjacent to the barriers shall be removed. 24. The areas of construction shall remain in a stable condition at the close of each construction day. 25. Any de-watering of trenches or other excavations required during construction shall be conducted so as to prevent siltation of wetland resource areas. All discharges from de-watering activities shall be filtered through haybale sediment traps,silt filter bags or other means approved by the Commission or its Administrator. 26. Within thirty days of completion of construction on any given portion of the project, all disturbed areas in the completed portion of the site shall be permanently stabilized with rapidly growing vegetative cover,using sufficient top soil to assure long-term stabilization of disturbed areas. 27. If soils are to be disturbed for longer than two months,a temporary cover of rye or other grass should be established to prevent erosion and sedimentation. If the season is not appropriate for plant growth,exposed surfaces shall be stabilized by other appropriate erosion control measures,firmly anchored,to prevent soils from being washed by rain or flooding. DURING CONSTRUCTION 28. A copy of the Order of Conditions,construction plans,and copies of the documents and reports cited in Condition# 11,shall be on the site upon commencement and during any site work for contractors to view and adhere to. 29. Erosion and sedimentation control devices shall be inspected after each storm event and repaired or replaced as necessary. Any accumulated silt adjacent to the barriers shall be removed. 30. Only clean fill,free of masonry,stumps,asphalt, and any other kind of waste material shall be used on the site. 31. All waste products,grubbed stumps,slash,construction materials,etc.shall be deposited at least 100 feet from wetland resource areas and 200 feet from rivers. 32. All filling or removal of waste material from the site shall be done in accordance with the regulations of the City of Salem Health Department. 33. Cement trucks shall not be washed out in any wetland resource or buffer zone area. Any deposit of cement or concrete products into a buffer zone or wetland resource area shall be removed by hand. 34. No fuel,oil,or other pollutants shall be stored in any resource area or the buffer zone thereto,unless specified in this Order of Conditions. 35. There shall be no pumping of water from wetland resource areas. 36. During construction,all drainage structures shall be inspected regularly and cleaned as necessary. 37. Immediately following drainage structure installation,all inlets shall be protected by silt fence,hayblae barriers and/or silt bags to filter silt from stormwater before it enters the drainage system. 38. The project shall not cause an increase in run-off onto adjacent properties,either during construction or when completed. 39. The applicant is hereby notified that failure to comply with all requirements herein may result in the issuance of enforcement actions by the Conservation Commission including,but not limited to,civil administrative penalties under M.G.L.Chapter 21A,section 16. POST CONSTRUCTION 40. All disturbed areas, slopes and proposed landscape areas shall be loamed and seeded or stabilized through the use of erosion control blankets or other approved means. All disturbed areas will be graded,loamed,and seeded prior to November 1 of each year, if possible. No disturbed areas or stockpiled material will be left unprotected or without erosion controls during the winter. • 41. Upon completion of construction,the applicant or current landowner shall submit the following to the Commission to request a Certificate of Compliance: (1) A letter requesting a Certificate including the following information: a. Name and address of current landowner; b. Name and address of the individual/trust or other entity to whom the Certificate is to be issued: c. Street address and lot number for the project;and d. DEP file number (2) A letter from a Registered Professional Engineering or Land Surveyor certifying compliance of the property with this Order of Conditions (3) An"As-Built"plan signed and stamped by a Registered Professional Engineer showing post-construction conditions and: a. As-built elevations of all drainage ways constructed within 100 feet of any wetland resource area; b. As-built elevations and grades of all filled or altered wetland resource areas,buffer zones and replicated areas;and c. Distances to all structures within 100 feet of any wetland resource area. 42. When issued,the Certificate of Compliance must be recorded at the Essex County Registry of Deeds. 43. If the completed work differs from that in the original plans and conditions,the report must specify how the work differs; at which time the applicant shall first request a modification to the Order. Only upon review and approval by the Commission,may the applicant request in writing a Certificate of Compliance as described above. 44. Erosion control devices shall remain in place and properly functioning until all exposed soils have been stabilized with final vegetative cover and the Commission and/or its Administrator has authorized their removal. 45. The following condition(s)shall extend beyond the Certificate of Compliance,in perpetuity,and shall be recorded as such on the Certificate of Compliance and in all future deeds to this property: ADDITIONAL CONDITIONS 48. Chemicals used in the pool shall be stored inside the shed away from the resource area. 137 Marlborough Road Salem,MA 01970 May 12,2004 City of Salem Conservation Commission 120 Washington Street Salem,MA 01970 Re: Notice of Intent Application for Pool 137 Marlborough Road Salem,MA 01970 Dear Conservation Commission Members, Attached please find seven(7)copies of letter of intent for proposed pool installation at the above referenced address for next scheduled meeting May 27,2004. The contractor has proposed design and construction to remain entirely outside the 50' 'No Build"zone. The pool will be constructed using concrete with a vinyl liner. The supporting documents as required include a certified plot plan(showing proposed pool,property lines, 50' no build zone and 30' no disturb zone" indicated on the property by boulders at 20'intervals per DEP final decision),a Locus map, a plot plan showing area elevations,a contractors proposed pool sketch,and a copy of quitclaim deed with references to final decision of DEP pertaining to this land. If you have any questions or concerns, please do not hesitate to contact me at my home telephone 978-740-0741 or my cell phone at 978-317-1195. The contractor will also accompany me at the May 27th meeting to answer any questions you may have. I look forward to meeting with you- Sincerely, (JC4�� John . 1 Cc: DEP-two copies Massachusetts Department of Environmental Protection ProwdednyoEP$ a Bureau of Resource Protection - Wetlands " t r" DEPFfIe N4mber.�..:,-ems" ' WPA Form 3 - Notice of Intent 6 a` { Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 t � °C enlr�al5acuer N�mue Cityrrown A. General Information 1. Project Location (Note: electronic filers will click on button for GIS locator): 131 MAdboro oh Rd SALEM 01996 a.Street Address b.Cityrrown c.Zip Code Latitude and Longitude, if Known: d.Latitude e.Longitude f.Assessors Map/Plat Number g.Parcel/Lot Number Important: When filling out z• Applicant: forms on, u SOhn FpR�ISTftu- only the tab computerter, use a.First Name b.Last Name c.Company 1 `l Mftr l key to move your cursor- d.Mailing Address do not use the �5k)LM 019 76 return key. e.Cityrrown f.State g.Zip Code q'78 RIFF-e UcAsr oe-I— "e h.Phone Number L Fax Number j.Email addresslue 'P� 3. Property owner(if different from applicant): [� Check if more than one owner C L-r4 J a.First Name b.Last Name c.Company d.Mailing Address Note: Before e.Cityrrown f.State g.Zip Code completing this form consult h.Phone Number L Fax Number j.Email address your local Conservation 4. Representative(if any): Commission regarding any a.Firm municipal bylaw or ordinance. b.Contact Person First Name c.Contact Person Last Name d.Mailing Address e.Cityrrown f.State g.Zip Code h.Phone Number i.Fax Numb u j.Email address ❑ Select if you want to see 5. Total WPA Fee Paid (from Appendix A,Wetland Fee Transmittal Form): _ Wetland Fee 7+a5�� (W/S 040- Transmittal a.Total Fee Paid b.State Fee Paid a Cityrrown Fee Paid Form. 6. General Project Description: InSTA(-` mil - 9fousid SwilkNA;m pooh in bsattar' o� stYwl:° (u Ino o .•{'s70A .J5O- On b",IA 7on1 wpafom3.dm•rev.Ofi103 Page 1 of 8 Massachusetts Department of Environmental Protection P �e°bx°sue , Bureau of Resource Protection - Wetlands � D�51e Number � �- WPA Form 3 - Notice of Intent '` ` s 0 �.,Document Tririsacdon Ndmlee Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 m Cityrrown A. General Information (continued) 7. Project Type Checklist: a. d Single Family Home b. ❑ Residential Subdivision c. ❑ Limited Project Driveway Crossing d. ❑ Commercial/Industrial e. ❑ Dock/Pier f. ❑ Utilities g. ❑ Coastal Engineering Structure h. ❑ Agriculture—cranberries, forestry i. ❑ Transportation I. ❑ Other S. Property recorded at the Registry of Deeds for: ESSEx a.County I �7 19 3 b.Book c.Page Number d.certificate#(if registered land) 9. Buffer Zone Only Is the project located only in the Buffer Zone of a bordering vegetated wetland, inland bank, or coastal bank, coastal beach, coastal dune, or salt marsh? a. 9 Yes If yes, skip to Section C. b. ❑ No If no, check the resource areas to be affected by this project, directly below. w afomldm•rev.06103 Page 2&8 Massachusetts Department of Environmental Protection REE Bureau of Resource Protection - Wetlands r�'� gfue Normer rcm WPA Form 3 - Notice of Intent Fµ - L�Tll� Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 arty 1Transa Numberj Citylrown C. Bordering Vegetated Wetland Delineation Methodology Check all methods used to delineate the Bordering Vegetated Wetland (BVW)boundary: Online Users: 1. 66 Final Order of Resource Area Delineation issued by Conservation Commission or DEP Include your (attached) document transaction 2. ❑ DEP BVW Field Data Form (attached) number (provided on 3. ❑ Final Determination of Applicability issued by Conservation Commission or DEP(attached) your receipt page)with all 4. d Other Methods for Determining the BVW Boundary(attach documentation): supplementary information you a. ❑ 50%or more wetland indicator plants submit to the Department. b. ❑ Saturated/inundated conditions exist c. ❑ Groundwater indicators d. ❑ Direct observation For all projects affecting other e. ❑ Hydric soil indicators Resource Areas, please f. ❑ Credible evidence of conditions prior to disturbance attach a narrative explaining how the resource area was D. Other Applicable Standards and Requirements delineated. PP 4 1. Is any portion of the proposed project located in estimated habitat as indicated on the most recent Estimated Habitat Map of State-Listed Rare Wetland Wildlife published by the Natural Heritage and Endangered Species Program? a. ❑ Yes d No If yes, include proof of mailing or hand delivery of NOI to: Natural Heritage and Endangered Species Program Division of Fisheries and Wildlife Route 135, North Drive Westborough, MA 01581 b.Dale of Map 2. For coastal projects only, is any portion of the proposed project located below the mean high water line or in a fish run? ❑ Yes❑ No If yes, include proof of mailing or hand delivery of NOI to: Massachusetts Division of Marine Fisheries 251 Causeway Street, Suite 400 Boston, MA 02114 [ Not applicable—project is in inland resource area only v afomld=•rev.0&03 Page 5 d 8 Massachusetts Department of Environmental Protection Provided by DEP: Bureau of Resource Protection - Wetlands _ DER He Number WPA Form 3 - Notice of Intent Document Traesadion Number- Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Cdylrown D. Other Applicable Standards and Requirements (continued) 3. Is any portion of the proposed project within an Area of Critical Environmental Concern (ACEC)? a.❑ Yes d/No If yes, provide name of ACEC (see instructions to WPA Form 3 or DEP Website for ACEC locations). Note:electronic filers click on Website. b.ACEC Online Users: 4. Is any portion of the site subject to a Wetlands Restriction Order under the Inland Wetlands Include your Restriction Act(M.G.L. c. 131,§40A)or the Coastal Wetlands Restriction Act(M.G.L. c. 130, § 105)? document transaction a. eYes ❑ No number (provided on your receipt 5. Is any activity within any Resource Area or Buffer Zone exempt from performance standards of the page)with all wetlands regulations, 310 CMR 10.00. supplementary Id / information you a. El Yes Ly No If yes, describe which exemption applies to this project: submit to the Department. b.Exempuon 6. Is this project subject to the DEP Stormwater Policy? a. ❑ Yes Id No b. If yes,stormwater management measures are required.Applicants should complete Appendix B: Stormwater Management Form and submit it with this form. c. If no, explain why the project is exempt: rJo , .A. ae--r o/J 2ttir�ot� E. Additional Information Applicants must include the following with this Notice of Intent(NOI). See instructions for details. Online Users: Attach the document transaction number(provided on your receipt page)for any of the following information you submit to the Department. i. E/USGS 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.) � z.�/Plans identifying the location of proposed activities (including activities proposed to serve as a Bordering Vegetated Wetland [BVWJ replication area or other mitigating measure)relative to the boundaries of each affected resource area. vryafoon3Aoo•rev.=03 Page 6 of 6 Massachusetts Department of Environmental Protection Provui6QbynEf' j LBureau of Resource Protection - Wetlands il r WPA Form 3 - Notice of Intent n t t4 * �r4c+;umentiransachon Nurtttrei Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Cilylrown E. Additional Information (continued) 3. L� Other material identifying and explaining the determination of resource area boundaries shown on plans(e.g., a DEP BVW Field Data Form). Online Users:Include your 4 ❑ List the titles and dates for all plans and other materials submitted with this NOI. document 5.❑ If there is more than one property owner, please attach a list of these property owners not transaction listed on this form. number (provided on 6.❑ Attach proof of mailing for Natural Heritage and Endangered Species Program, if needed. your receipt page)with all 7 ❑ Attach proof of mailing for Massachusetts Division of Marine Fisheries, if needed. supplementary information you S.id Attach Appendix A, see next page. submit to the Department. s.❑ Attach Appendix B, if needed. F. Fees The fees for work proposed under each Notice of Intent must be calculated and submitted to the Conservation Commission and the Department(see Instructions and Appendix B.Wetland Fee Transmittal Form). No fee shall be assessed for projects of the federal government,the Department, or cities and towns of the Commonwealth. Applicants must submit the following information (in addition to pages 1 and 2 of Appendix B)to confirm fee payment: (-o3ol s /Z •oy 1.Municipal Check Number 2.Check date 61 19 3iso� 3.State Check Number 4.Check date 3-6HIQ i DFia. iST�t_l_ 5.Payor name on check:First Name 6.Payor name on check:Last Name w af..Id.•rev.06/03 Page]of 9 Massachusetts Department of Environmental Protection Provided by°E � � D ��M Bureau of Resource Protection -Wetlands fa 1)EP Ffie N ml �a xM: ,j,& ' WPA Form 3 - Notice of Intent oAIR, ocument7ransac6um ; Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 cityrrown G. Signatures and Submittal Requirements 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 requirements of M.G.L. c. 131, §40. Notice must be made in writing by hand delivery or certified mail (return r ei t req este all abutters .thin 100 W of the property r e of the project location. Sign lure of Ap :cant V Date Signature of Property Owner(if different) Date Signature of Representative(if any) Dale For Conservation Commission: Two copies of the completed Notice of Intent(Form 3), including supporting plans and documents;two copies of pages 1 and 2 of Appendix B; and the city/town fee payment must be sent to the Conservation Commission by certified mail or hand delivery. For DEP: One copy of the completed Notice of Intent(Form 3), including supporting plans and documents; one copy of pages 1 and 2 of Appendix B; and a copy of the state fee payment must be sent to the DEP Regional Office(see Instructions)by certified mail or hand delivery. (E-filers may submit these electronically.) Other: If the applicant has checked the"yes" box in any part of Section D, 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. wpaf..3.dm•rev.06103 Page 8 of 8 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands WPA Appendix A - Wetland Fee Transmittal Form Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Important: A. Applicant Information When filling out - forms on the 1. Applicant: computer,use only the tab �/ t7rV Z�f�.l sag G�i key to move a.First Name b.Last Name c.Company your cursor- IY7 MVDr'Ibot-okAGh ?d do not use the d.Mailing Address tZ return key. SE}j_�p,� -�} btg7D e.City/rown f. tat TS e i g.Zip Code 478 7yo D r7 / h.Phone Number �* 2. Property Owner(if different): a.First Name b.Last Name c.Company d.Mailing Address e.Cityf rown f.Stale g.Zip Code h.Phone Number 3. Project Location: 1 ,77 MkttZt-40,'0R4U&H QO 5,14LE M - a.Street Address b.Cityrrown To calculate B. Fees filing fees, refer to the category Notice of Intent(Form 3) or Abbreviated Notice of Intent(Form 4): fee list and examples in The fee should be calculated using the following six-step Section D of 9 9 p process and worksheet. Please see this form. Instructions before filling out worksheet. Step 1/Type of Activity: Describe each type of activity that will occur in wetland resource area and buffer zone. Step 2/Number of Activities: Identify the number of each type of activity. Step 3/Individual 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 Riverfront 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 5/Total 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. Wpafa ml. c•Appendix B•rev.9003 Page 1 0(3 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands WPA Appendix A — 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 Step Step 4/Subtotal Activity of Activities 3/Individual Fee Activity Fee Step 5/Total Project Fee: Step 6/Fee Payments: Total Project Fee: a.Total el�f m step s State share of filing fee: b.1�otalee le$12.50 City/Town share of filling fee: c.�toan P 12.50 Abbreviated Notice of Resource Area Delineation (Form 4A): The fee is calculated as follows(check applicable project type): 1. ❑ single family house project a.feet of BVW x$1.00= b.Total fee not to exceed$1,000 2. ❑ all other projects a.feet of BVW x$1.00= b.Total fee not to exceed$1,000 State share of filing fee: 3. 1/2 of total fee less$12.50 City/Town share Of filing fee: q 1/2 of total fee plus$12.50 Wpalor ld.•Appntlu B•rev.grM3 Page 2 of 3