45 MARCH STREET - CONSERVATION COMMISSION jf ui
A , ys
1
Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Wetlands
WPA Form 1 - Request for Determination of Applicability City/Town
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):
5`S r110/ec# sr. sifter
Street Address City/Town
36 aLZra
Assessors Map/Plat Number Parcel/Lot Number
b. Area Description (us/e additional p/aper, if ne/cessary): /7 f/
c. Plan and/or Map Reference(s):
Title - Date
Title Date
Title Date
2, a. Work Description (use additional paper and/or provide plan(s) of work, if necessary): `//
407 Y1 7vt S/n� le .SYS/ A.1, i7/7rrh
WKf �Ld2.G /�/�d.t=O12d��"L
wpaforml.doc•rev.07/14/04. Page 2 of 4
l
Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Wetlands
WPA Form 1 - 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 Actor 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).
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3. a. If this application is a Request for Determination of Scope of Alternatives for work in the
Riverfr nt 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 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 Aoc•rev.07/14/04. Page 3 of 4
Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Wetlands
/ City/Town
WPA Form 1 - 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 (see Attachment)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:
1liL iyae2 /QYGyEL-
Name
703 �w s�-
Mailing Address
��si8ob Y
Cityliown
State Zip Code
Signatures:
I al nde land that notifcati of this Request will be placed in a local newspaper at my expense
i accorda a wit ection 1 .0 (3)(b)(1) of the Wetlands Protection Act regulati ns.
Signature of Applica t Date
Signature of Representative(if any) Date
wpafor l.doc•rev.07114104. Page 4 of 4
MORTGAGE INSPECTION
SAY STATE SURVEYING ASSOCIATES INC. JOB
100 CUMMINGS CENTER, SUITE#316J, SEVERLY,MA., 01915
Nom
�
g M p�(� and not LOCATION :. trd:.d. �••- ; 1• • 1?Thts is a mortgm®®I ftrg Von this plot t............. Irtstrtaiard aurwy,thorefon thts plot pian is for
s'Z O mortgage "speed"purPom of".It is NOT to
SCALE : 1" =7,0 DATE ............ .:....4........... be used to estaMish boundaries or for the
p ZZ$ aordouctlon of any type of irnprovemsot others.
a9n —ate
ats-
REFERENCE : K' G?;,,,Q . ® .�� 3)fa Y This vxM is basad on and t 111196 do not
neassoBushesNy roll tenons e�trw
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°°' ••• . "' ••. 4)Whenever an GIVING&15 1'b or NGs.an bab+snent
9A®I U S FI rUJ41i U AL Garvey 1s r�esi iabGd to determine 131`01311"YTO: ..» ..__....._.. _. ...»..._ _ _ .. arses,and any Possible W os •
The location of the buildings)es shown,either 5)ops thio t ars sPprominaa,and am to be
compiled with the local toeing sotbacks at the time of used only for the determination of zoning.Not to
construction or is exempt from violsdon�erdac be used to 94011111811 WQPatV 1111111114&r
action under Mass.G.L Title VI Chapter 1�g)in my p"*Msslonal opWon the building(s)$1110
lsea&ad in ttte aPGGia9 Rood 101 .es
dalfrad by NM.M ZSz0/Du coos 8 1-5-95
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MiEi4 !S FLOOD ZbN�
NOTE: LOT CONFIGURATION TAKEN
FROM ASSESSORS MAP
39.10'
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MARCH A RV H S 1, onaw�evoxaa�n� sear
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11UT 7110U1D BE A6MY/FD TO
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ILIMassachusetts Department of Environmental Protection
Bureau of Resource Protection - Wetlands
WPA Form 2 — Determination of Applicability
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40
A. General Information
Important:
When filling out From:
forms on the SALEM
computer, use Conservation Commission
only the tab
key to move To: Applicant Property Owner(if different from applicant):
your cursor-
do not use the Michael Rygiel
return key. Name Name
703 Lowell Street
VQ Mailing Address Mailing Address
Salem MA 0
Sale wn State Zipp Cod Code City(rown State Zip Code
7. Title and Date (or Revised Date if applicable)of Final Plans and Other Documents:
Mortgage Inspection 5/28/04
Title Date
Title Date
Title Date
2. Date Request Filed:
February 24, 2005
B. Determination
Pursuant to the authority of M.G.L. c. 131, §40,the Conservation Commission considered your
Request for Determination of Applicability, with its supporting documentation, and made the following
Determination.
Project Description (if applicable):
The removal of existing signle story addition and replace with a secondary point of egress for all three
floors of the building.
Project Location:
45 March Street Salem
Street Address Cityfrown
MAP 36 LOT 0220
Assessors Map/Plat Number Parcel/Lot Number
wpafo.2.eoc•rev.7113104 Page i of 5
Y ,
Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Wetlands
WPA Form 2 — Determination of Applicability
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40
B. Determination (cont.)
The following Determination(s)is/are applicable to the proposed site and/or project relative to the
Wetlands Protection Act and regulations:
Positive Determination
Note: No work within the jurisdiction of the Wetlands Protection Act may proceed until a final Order of
Conditions (issued following submittal of a Notice of Intent or Abbreviated Notice of Intent)has been
received from the issuing authority (i.e., Conservation Commission or the Department of
Environmental Protection).
❑ 1. The area described on the referenced plan(s)is an area subject to protection under the Act.
Removing,filling,dredging,or altering of the area requires the filing of a Notice of Intent.
❑ 2a.The boundary delineations of the following resource areas described on the referenced
plan(s) are confirmed as accurate. Therefore, the resource area boundaries confirmed in this
Determination are binding as to all decisions rendered pursuant to the Wetlands Protection Act and its
regulations regarding such boundaries for as long as this Determination is valid.
❑ 2b. The boundaries of resource areas listed below are not confirmed by this Determination,
regardless of whether such boundaries are contained on the plans attached to this Determination or
to the Request for Determination.
❑ 3. The work described on referenced plan(s)and document(s) is within an area subject to
protection under the Act and will remove, fill, dredge, or alter that area. Therefore, said work
requires the filing of a Notice of Intent.
❑ 4. The work described on referenced plan(s)and document(s) is within the Buffer Zone and will
alter an Area subject to protection under the Act. Therefore, said work requires the filing of a
Notice of Intent.
❑ 5. The area and/or work described on referenced plan(s)and document(s)is subject to review
and approval by:
Name of Municipality
Pursuant to the following municipal wetland ordinance or bylaw:
Name Ordinance or Bylaw Citation
wwform2.Gw•rev.7/13/04 Page 2 of 5
i
Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Wetlands
WPA Form 2 — Determination of Applicability
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40
B. Determination (cont.)
❑ 6. The following area and/or work, if any, is subject to a municipal ordinance or bylaw but not
subject to the Massachusetts Wetlands Protection Act:
❑ 7. If a Notice of Intent is filed for the work in the Riverfront Area described on referenced plan(s)
and document(s),which includes all or part of the work described in the Request, the applicant
must consider the following alternatives. (Refer to the wetland regulations at 10.58(4)c. for more
information about the scope of alternatives requirements):
❑ Alternatives limited to the lot on which the project is located.
❑ Alternatives limited to the lot on which the project is located, the subdivided lots, and any
adjacent lots formerly or presently owned by the same owner.
❑ Alternatives limited to the original parcel on which the project is located, the subdivided
parcels, any adjacent parcels, and any other land which can reasonably be obtained within
the municipality.
❑ Alternatives extend to any sites which can reasonably be obtained within the appropriate
region of the state.
Negative Determination
Note: No further action under the Wetlands Protection Act is Y required b theapplicant. However, if the
q
Department is requested to issue a Superseding Determination of Applicability,work may not proceed
on this project unless the Department fails to act on such request within 35 days of the date the
request is post-marked for certified mail or hand delivered to the Department. Work may then proceed
at the owner's risk only upon notice to the Department and to the Conservation Commission.
Requirements for requests for Superseding Determinations are listed at the end of this document.
❑ 1. The area described in the Request is not an area subject to protection under the Act or the
Buffer Zone.
® 2. The work described in the Request is within an area subject to protection under the Act, but will
not remove, fill, dredge, or alter that area. Therefore, said work does not require the filing of a
Notice of Intent.
❑ 3. The work described in the Request is within the Buffer Zone, as defined in the regulations, but
will not alter an Area subject to protection under the Act. Therefore, said work does not require
the filing of a Notice of Intent, subject to the following conditions (if any).
❑ 4. The work described in the Request is not within an Area subject to protection under the Act
(including the Buffer Zone). Therefore, said work does not require the filing of a Notice of Intent,
unless and until said work alters an Area subject to protection under the Act.
wpaform2.doc•rev.7113/04 Page 3 of 5
Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Wetlands
WPA Form 2 — Determination of Applicability
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40
B. Determination (cont.)
❑ 5. The area described in the Request is subject to protection under the Act. Since the work
described therein meets the requirements for the following exemption, as specified in the Act and
the regulations, no Notice of Intent is required:
Exempt Activity(site applicable statuatory/regulatory provisions)
❑ 6. The area and/or work described in the Request is not subject to review and approval by:
Name of Municipality
Pursuant to a municipal wetlands ordinance or bylaw.
Name Ordinance or Bylaw Citation
C. Authorization
This Determination is issued to the applicant and delivered as follows:
❑ by hand delivery on by certified mail, return receipt requested on
Date Date
This Determination is valid for three years from the date of issuance (except Determinations for
Vegetation Management Plans which are valid for the duration of the Plan). This Determination does not
relieve the applicant from complying with all other applicable federal, state, or local statutes, ordinances,
bylaws, or regulations.
This Determination must be signed by a majority of the Conservation Commission. A copy must be sent
to the appropriate DEP Regional Office (see Attachment)and the property owner(if different from the
applicant).
Signature J: k2
March 10, 2005
Date
wpafo.2.doc•rev.7113/04 Page 4 of 5
LIMassachusetts Department of Environmental Protection
Bureau of Resource Protection - Wetlands
WPA Form 2 — Determination of Applicability
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40
D. Appeals
The applicant, owner, any person aggrieved by this Determination, any owner of land abutting the land
upon which the proposed work is to be done, 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 Department of Environmental
Protection Regional Office(see Attachment)to issue a Superseding Determination of Applicability. The
request must be made by certified mail or hand delivery to the Department,with the appropriate filing fee
and Fee Transmittal Form (see Request for Departmental Action Fee Transmittal Form)as provided in
310 CMR 10.03(7)within ten business days from the date of issuance of this Determination. 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 Determination which is being appealed. To the extent that the Determination is based on
a municipal ordinance or bylaw and not on the Massachusetts Wetlands Protection Act or regulations, the
Department of Environmental Protection has no appellate jurisdiction.
wpaform2.doc•rev.7/13/04 Page 5 of 5
Serviceim
I� U.S. Postal
CERTIFIED MAIL.
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N *DepartmenS t.of Environmental Protection,
o NER®�- Wetlands & Waterways r
r, Cain 511 Floor One Winter Street
-O67" Boston, MA 02108
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■ If a postmark on the Certified Mail receipt Is desired,GIease present the arti-
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receipt is not needed,detach and affix label with postage and mail.
IMPORTANT: Save this receipt andpresent it when making an Inquiry.
Internet access to delivery InlormaNn is not available on mall
addressed to APOs and FPOs.
SENDER: • • Y
■ Complete items 1,2,and 3.Also complete A. Signa uro
item 4 if Restricted Delivery is desired. C/1 ❑Agent
X
■ Print your name and address on the reverse C v ❑Addre as
so that we can return the card to you. B. Recei Name C. Date of Dell
eli ery I
IN Attach this card to the back of the mailpiece,
or on the front if space permits.
1. Article Addressed to: D. Is tlel eryapdQ�1�d" t(lil"m t 11 Yes
If YE ,ent,W,d w: ❑ No
Department of Environmental ProtectionONE WINTER ST. 4th FL I
NERO - Wetlands & Waterways pnpl- -
5rh Floor, One Winter Street 3. Service Type
Boston, MA 0210$ Of Certified Mail ❑ Exp ass Mail
❑ Registered ❑ Return Receipt for Merchandise
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HS M61-cll, Sf. Alp 4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number7.002 '24101 0003' 2794' 5958
(rmnsfer from service label)
PS Form 3811, February 2004 , Domestic Return Receipt 102595-02-M-1540 it
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UNITED STATES POSTAL SERVICFirst-Class Mail _
6EsT1'ge R'Fees�Paid
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I • Sender: Please prin t na dddress, and ZIP+ Ni this box
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I Salem Conservation Commission
120 Washington Street,3rd FI
Salem,MA 01970 C.)
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SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY
■ Complete items 1,2,and 3.Also complete 'gi ature
item 4 if Restricted Delivery is desired. 0 Agent
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or on the front if space permits. �70
D. Is delive address Mar nt from item 17 0 Yes
1. Article Addressed to: If YES,enter delivery address below: 0 No
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Registered 0 Return Receipt for Merchandise
0 Insured Mail 0 C.O.D.
4. Restricted Delivery?(Extra Fee) 0 Yes
2. Article Number -
(Transfer from semicetabeQ - : 7002 2410 0003 2794 59.65
PS Form 3811, February 2004 _ Domestic Return Receipt 102595-02-M-1540
UNITED STATES POSTAL SERVICE First-Class Mail
Postage&Fees Paid
USPS
Permit No.G-10
I • Sender: Please print your name, address, and ZIP+4 in this box
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Salem Conservauon CnmmisslotlM o
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120 Washington Street,3rd A r
Salem,MA 01970
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�v CITY OF SALEM
CONSERVATION COMMISSION
City of Salem
Conservation Commission
Will hold a public hearing for a Request for a Determination of Applicability under the Wetlands
Protection Act, Massachusetts General Laws, Chapter 131, Section 40 and Salem's Ordinance
Pertaining to General Wetlands at the request of Michael Rygiel, 703 Lowell Street, Peabody,
MA 01960. The purpose of the hearing is for a determination of work related to the demolition
of a single-story addition and replaced by a secondary point of egress for all three floors at 45
March Street. This hearing will be held on Thursday, March 10, 2005 at 6:00 p.m. in City Hall
Annex, Room 313, 120 Washington Street.
•
Kevin P. Cornacchio
Chairman
Please print ad on:
March 3, 2005
Please send bill to:
Michael Rygiel
703 Lowell Street
Peabody, MA 01960
(978) 535-2388
120 WASHINGTON STREET, .SALEM, MASSACHUSETTS 01970 TEL: 978.745.9595 FAx: 978.740.0404 WWW.SALEM.COM
City of Salem Department of Planning & Community Development
Check/Cash Receipt and Tracking Form
Please complete lbrm ane make t►m cop/es.
Dace iseoeived 3 0 5—
Amount Received 5 0 D
Forth of Payment deft rwh
CHECK PAYMENTS:
write check number /-7 /
CASH PAYMENTS:
write client initials
Q sign Perri Appkation Fee
UC'D e atlon Commkslon Fee
Payment received for Rarm*v Moira Fee
what service?
0 Old Town Hag Rental Fee
0 odw
Name of staff person
receiving payment
Additional Notes
MICHAEL D. RYGIEL X712912 a3 14 9
NANCY J. RYGIEL r
P.O. BOX 2282 80
J
F PEABODY, MA 019DAtE
3i PAYTOT E $ '0491 J
ORDER OF ^ .ADD �/
g _ 'zA
l DOLLARS r m
M'MO �MI101 12
r
421, 13 ? i298r: 8006225448116 0149
�Check and Forne DPCD Finance
Con 2:Appkation Re
i•
LlMassachusetts Department of Environmental Protection
Bureau of Resource Protection - Wetlands -so 1.001
WPA Form 1 - Request for Determination of Applicability City/Town
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 RECEIVE®
A. General Information FEB 2 5 2005
Important:
When filling out 1. Applicant: DEPT. OF PLANNING&
forms on the /lJlcfWeL KYC7/EL—
only the tab key COMMUNITY DEVELOPMENT
computer, use Name E-Mail Address
to move your �03 >-0WE� s�
cursor-do not Mailing Address
use the return jool6o6y //1,4 0/1I60
key. Cityfrown State Zip Code
g78 - 53S�-2,388' 97rY -S3S- S3 YS
Q Phone Number Fax Number(if applicable)
5A2. Representative (if any):
Firm
Contact Name E-Mail Address
Mailing Address
City/Town State Zip Code
Phone Number Fax Number(if applicable)
B. Determinations
1. I request the C�1er 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 Municipality
N e. whether the following scope of alternatives is adequate for work in the Riverfront Area as
depicted on referend plan(s). L a
/-,�o_sru>� ///OGri�f.er,,o /G✓d-u.[.d ..y(J� L'.C4Sl/ 4 /1/r/cll7'e1.1T QZ'�
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�llGa� g� a000s�,0 ..r.�iv�r�r /..;.G/ ,ns�✓� leas"/ l�eawr�a-,/ %�
wpaforml.tloc-rev,07/14104. Wq 4146ke;W n,d�L Page 1 of 4
Y
Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Wetlands
/
WPA Form 1 - Request for Determination of Applicabilit City/Town
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 REFIVED
A. General Information FEB 2 5 2005
Important:
When filling out 1. Applicant: DEPT.OF PLIwNiNG&
forms on the /d1rcN9rL /Q?/�7/EL COMMUNITYOEVELOPMENT
computer, use Name
only the tab key E-Mail Address
to move your 703 ST
cursor-do not Mailing Address
use the return 1 6 ogoD`1 /!'!1f 0/960
key. City/Town State Zip Code
978 - 63S-73e-K 972' -S.3SS- S3Yrr
Phone Number_ —_. _ __Eax.Number_(if-applicable) --
2. Representative (if any):
49T
Firm
Contact Name E-Mail Address
Mailing Address
City/TownState Zip Code
Phone Number Fax Number(if applicable)
B. Determinations
1. I request the (�`1 y r 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 Municipality
E! e.whether the following scope of alternatives is adequate for work in the Riverfront Area as
depicted on
. ) referen�d plan(s).
Azo 6-64;"-0
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eiS'CA-e� S/4
A. "'4_ -6.1-11 ,nv7/k�A
w0aforml.doc-rev.07/14/04. .(/q L4
.,-/— yp'4b4;t eeekl�w,/h--4'r'�t Page 1 of 4
Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Wetlands
�
WPA Form 1 - Request for Determination of Applicability City/Town
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):
YS H sr. S/f«
Street Address City?own
3 6 D Lz0
Assessors Map/Plat Number Parcel/Lot Number
b. Area Descriptio//n (use additional paper, if necessary): n / �J
AZ-s/44Fr.�rL,�Ll- Ao,'41 � 6,t 7(/K-
�rjJee- Zci e—
It
c. Plan and/or Map Reference(s):
Title Date ,
Title Date
Title Date
2. a. Work Description (use additional paper and/or provide plan(s) of work, if necessary): / /7
lee vr,otla- .Qki&*Ar � S-1-1y 11 .S741-Y a acL(/Y7cXI
wpa(o.l.doc•rev.07/14/04. Page 2 of 4
v I
Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Wetlands
�
WPA Form 1 - Request for Determination of Applicability Ciry/Town
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40
C. Project Description (cont.)
b. Identify-provisions of the Wetlands Protection Actor 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).
/Zfod`77f4�o>-,.s' yp G� eX(S11�u �o%Prim
3. a. If this application is a Request for Determination of Scope of Alternatives for work in the
Riverfr t Area, indicate the one classification below that best describes the project.
ZSingle 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.)
wpaformi Am•rev.07/14/04. Page 3 of 4
r Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Wetlands
WPA Form 1 - Request for Determination of Applicability Cityrrown
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 (see Attachment)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:
,*1:wit-Name
Mailing
703 �w� sfi
Mailing Address
lA�itsob Y
City/town
State Zip Code
Signatures:
I al nde land that notificati of this Request will be placed in a local newspaper at my expense
i accords a wit coon 1 .0 (3)(b)(1)of the Wetlands Protection Act regulatns.
02 o�Y Q�
Signature of lira t Date
Signature of Representative(if any) Date
wpaformt.dw•rev.07/14/04. Page 4 of 4
MORTGAGE INSPECTION
BAY STATE SURVEYING ASSOCIATES INC.
100 CUMMINGS CENTER, SUITE N 316J, SEVERLY,MA., 01915
and not an
LOCATION :. .4cd:.1. �•••.. .;......... 1)TMs 1s•nw%w Inspection survey dwakwo"plot plan Is for
t............. _
5-Z O iaormaps nspeotlar pwvom 0*.it is"or to
SCALE : V ZOO DATE .»......... ... ......»... be used to establish boon was ortordw
REFERENCE : ... •� , ..
ZZ. . ' >a TNs atttwy b based°"st"v')' °1h"s.
D
0Ye11ea.drubs.fenow and tris lines do not
31
O whsrmw n offset
ffses I,+.o IIs"an bub mord
.....+••.... .... •• 4}Ylllrerrarar sosurvey to ne r�iMnd d W detsrm prop"
T0: . iZA01 US FirV>9�u/}L„__ __ Ines.and arty possible
The location of the building(s)wshown.eltlter 51 tMae4 drown M appev:i= and are to be
compiled with the load zoning setbacks d the time of mud a*for dM detarrttetion of zordnp.Not to
—construction or is aympt_frwn violation entorcansnt be_used_to_ Is� ty
Y lin
action under Maas ti.L Title VII Chapter d0A SecontiT {)In my Pws 10-
opinion tie balfdtnols)
leaned In to apsoW Ileod hEwd strr6 es
ddlnedbydW.D.WIPd 2��p2000J8 $'S'8$
'� Mt�F iS iNF[DOD ZdN� UfF=��
NOTE: LOT CONFIGURATION TAKEN
FROM ASSESSORS MAP
,
39./0' '
q: y,000L 9
AL
8
A4 -
NOCK R
3- WOOD
43- NS
MARCH ST
�TM� arro*
M GIIM�G�M CONTO�ON
\IY OOWM�MT?IML NOT 4/q.Y