25 OSBORNE HILL DRIVE - CONSERVATION COMMISSION Or, 2 ia�
RDA Status Sheet
Address: Date Submitted: Z �.e r-
Contact Name: � � ,�/ Proposed activity: a'.z f�
Phone: q-(�P �e 0/6
7
.Application Complete
di,oCorrect Fee Received
e-Legal Ad Sent o Legal Ad Confirmed -crOnline
,-o Added to Agenda -a-Agenda to Applicant
o Agent Comments to Commission
Hearing Opened: I/ X��Gentinued: —Site Visit:
hermit Sent to Applicant and DEP
EConfirmation of Delivery
❑ added to database
Notes:
HACON COMM\Admiuistrative\project status sheet\RDA status sheet 2013-10-30.doc
Ol ,
4-28-2015
Dear Salem Conservation Committee,
My name is David Mackey of 25 Osborne Hill Drive and I am before you to seek approval so I may make
improvements to the backyard of my home. These improvements are within the buffer zone of a dried
stream and the proposed work is on the far edge of the buffer zone.
The proposed work is to include:
- Patio against the rear of the house
- Improvements to a stone wall abutting the house
- Raising the stone wall on the rear property line to prevent future runoff of topsoil
- PVC fence along boundary line of backyard
- Possible increase in deck size above patio area
Improvements are to be made with all work conforming to code and applicable requirements. All work
will result in better runoff control of yard to prevent a washout of silt into the conservation area. Silt
.,, fence control is already in place and in full functional condition.
The attached documents and images detail all proposed work and I am available to answer any
additional questions.
Thanks you and regards,
David Mackey
Tom Devine Apr 22 (6
• days
ago),
to me
Hi David,
It sounds to me like you plan limited work only in the buffer zone.We should talk through your plan
again, but based on what you told me already, I think the appropriate application would be the Request
for Determination of Applicability:
http://W Ww.mass.goy/eea/age ncies/ma ssd ep/service/a p p roya Is/W pa-form-1.htm I
There is a $25 fee and you have to provide a deposit to the Salem News to publish a legal notice, which I
will draft.There is a Salem News Deposit form on the Conservation Commission
webpage: http://www.salem.com/Pages/SalemMA ConComm/index
You have to submit the fee,Salem News deposit check,and 8 copies of the application and plans to me
two weeks before the meeting you wish to be heard at.The Schedule is also on the Commission's
webpage.
I'm happy to talk with you further or meet with you if it will be helpful as you prepare your submittal.
• Best,
Tom
Tom Devine, AICP I Senior Planner
City of Salem Department of Planning & Community Development
120 Washington St., 3rd Floor I Salem, MA 01970
(V) 978-619-56821 (F) 978-740-0404
tdevine(d.)salem.com I salem.com
•
• THE SALEM NEWS
REQUEST FOR LEGAL NOTICE
I understand that by signing this form, I am agreeing to the cost of the legal notice to be published in the
newspaper.
Payment is required at the time of the legal notice being received by the city and before it is published
in the newspaper.
Please make checks payable to THE SALEM NEWS:
The Salem News
Attn: Legal Notice
32 Dunham Road
Beverly, MA 01915
Prepaid cost required to run:$260
• 'Important:Average legal notice costs are estimated; customer will either be refunded or billed after
the legal notice is published.
Check p VA (attach check)
If payment is not received,the legal notice will be cancelled.
(Signature)
•
BRENDA MACKEY 825
2 SUNSET RD (978)741-1511 53-13410 MA
SALEM,MA 01970 14753
Pa
Orde-o{o-f a f- -sem•�"'� I $ z • U U
11nQ ✓��� 1�N'L k u11C� Dollars
Bankof America
ACH 8/T 011000138 /Q�-(/'/n�/,{7 Y����" ��
For Y� v" - C \ w
1:0 1 1000 1 381: 00460 263 i i6 1,1108 25
Hwru cum a Es EFFiELD^
BRENDA MACKEY 824
2 SUNSET RD (978)741-1511 5313/110 MA
SALEM,MA 01970
14753
Date
Pay to the 1, 1 �,
Order of `e Q S/� p/�� I�pC $ �0 U
TW J R 4 A l r-, j mel Dollar s a
BankofAmerica.400-0- j
ACH M 011000138
For LIQ —LCC
1:0110001381: 00460 26 3 1 i6 io'08 24
Haran nm
• 1-_ AVE SHEFFIELD^'
t
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
A. General Information
Important:
When filling out 1. Applicant:
forms on the David Mackey dtmackey@gmail.com
computer, use Name E-Mail Address
only the tab key
to move your 25 Osborne Hill Drive
cursor-do not Mailing Address
use the return Salem MA 01970
key. Cityrrown State Zip Code
978-578-0167
Phone Number Fax Number(if applicable)
2. Representative (if any):
Finn
Contact Name E-Mail Address
Mailing Address
City/Town State Zip Code
• Phone Number Fax Number(if applicable)
B. Determinations
1. 1 request the Salem 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.
fel d. whether the area and/or work depicted on plan(s) referenced below is subject to the jurisdiction
r of any municipal wetlands ordinance or bylaw of:
5otkeV' 6n
Name of Municipality
❑ e. whether the following scope of alternatives is adequate for work in the Riverfront Area as
depicted on referenced plan(s).
•
wpafonnl.doc Page 1 of 4
Massachusetts Department of Environmental Protection
Bureau of Resource Protection -Wetlands
�
WPA Form 1 - Request for Determination of Applicability Cityfrown
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):
7 SVS v�2 0( 11 D` 5G1-0-k-\
Street Address $ x / 78 City/Town
I,o-t-.t4l�{
Assessors Map/Plat Numb r Parcel/Lot Number
b. Area Description (use additional paper, if necessary):
yr.,SStJ 111', Z Vr 4r, c tNvIt
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):
1`iA�S.Q, (Y'g�t✓�i✓r
V Vtn k'r' ro; 5 chi 1 h L_{.i 1 D�2��2� 1✓1/ r�wlvac�'
2 1 tM�(�,nL rP_ DRi+ ::/r��e Q I1 p �q.CJL_C[Jr ✓1P✓ (�j'F GI GIA? I^I]
��P I/CtiT ,�LLL_t]i- 1- u� SOIL �dw� �yl�Vwt' S4
b.ter 1— ILfUI�r/t_V� � SQ2 n1Arl
Ly1� a te. ItI IA b J W I T-Lt /r VAIe— Rneyl^ kt.u�t_
/ P(xS� to It 1C..n K-�.9fZ I 01tG` C';-Z2 6x4Gi 47 huIJY-�
wwpaaforml.doc Page 2 of 4
Massachusetts Department of Environmental Protection
Bureau of Resource Protection -Wetlands
OMassachusefts
CirylrownWPA Form 1- Request for Determination of Applicability Wetlands Protection Act M.G.L. c. 131, §40
C. Project Description (cont.)
b. Identify provisions of the Wetlands Protection Act or regulations which may exempt the applicant
from having to file a Notice of Intent for all or part of the described work(use additional paper, if
necessary).
NjA 3. a. If this application is a Request for Determination of Scope of Alternatives for work in the
Riverfront Area, indicate the one classification below that best describes the project.
❑ Single family house on a lot recorded on or before 8/1/96
❑ Single family house on a lot recorded after 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.
N14 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.)
•
wpaf ntdm Page 3 of 4
Massachusetts Department of Environmental Protection
Bureau of Resource Protection -Wetlands
WPA Form 1 - Request for Determination of Applicability City/Tom
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40
D. Signatures and Submittal Requirements
I hereby certify under the penalties of perjury that the foregoing Request for Determination of Applicability
and accompanying plans, documents, and supporting data are true and complete to the best of my
knowledge.
I further certify that the property owner, if different from the applicant, and the appropriate DEP Regional
Office were sent a complete copy of this Request(including all appropriate documentation)
simultaneously with the submittal of this Request to the Conservation Commission.
Failure by the applicant to send copies in a timely manner may result in dismissal of the Request for
Determination of Applicability.
Name and address of the pro arty`ownner:
n
V' I/lLcCi
Name
Mailing Address
SGIe
City/Tom
Y�'t ✓� U l�c 7 0
State Zip Code
• Signatures:
I also uncle d that notification of this Request will be placed in a local newspaper at my expense
in accordice ith r
ion 10.05(3)(b)(1)of the Wetlands Protection Act regulations.
Signature of Applicant tate
Signature of Representative(if any) Date
I •
wpaforml.doc
Page 4 of 4
PROFESSIONAL SERVICES AGREEMENT MA`Kc NCI STANOARO iCnM
THIS AGREEMENT IS TO CONFIRM THAT SURVEYING AND/OR ENGINEERING SERVICES ARE TO BE
PERFORMED BY: EASTERN LAND SURVEY ASSOCIATES, INC.
104 Lowell Street, Peabody, Mass. 01960
�iEINAFTER REFERRED TO AS SURVEYOR/ENGINEER AS REQUESTED BY:
NAME: David Mackey ADDRESS: 25 Osborne Hill Drive
TITLE: STATE & ZIP CODE: Salem, MA 01970
SURTITE
fY
978-578-0167 srA:QTour
COMPANY: TELEPHONE: To RAPHIC
HEREINAFTER sukv Y
EREINAF ER REFERRED TO AS CLIENT: E
SCOPE OF SERVICES: As per enclosed proposal dated September 3, 2014 F 12795 ARC TITETV
INDICATED AT RIGHT AND/OR AT BOTTOM gduNOARY
SuaVEY
OWNER OF LAND AND LOCATION: David Macke MONUMENIATION
Lot 1 2 Osborne Hill Drive Salem STQKNE
SPECIAL CONDITIONS: CONTINUATION
SURVEY
CON{T,yNGCTioN
S AM
FURNISHING OF DOCUMENTS: THE FOLLOWING QUANTITY OF DRAWINGS. ESTIMATES, AND SPECIFICATIONS ARE TO BE FURNISHED
BY THE SURVEYOR/ENGINEER:
FEE: THE FEE FOR THE ABOVE DESORIBED SERVICES WILL BE ONE OR MORE OF THE FOLLOWING:
17-71
TOTAL SUM OF $ 800.00 HOURLY BASIS PLUS EXPENSES.
OTHER
A RETAINER IN THE AMOUNT OF $ 400.00 WI`` E REQUIRED PRIOR TO THE INITIATION OF THE ABOVE
DESCRIBED SERVICES. THIS AMOUNT WILL BE CREDITED TO THE IEIaIN THE BILLING FOR THE AFOREMENTIONED SERVICES.
THE FEE WILL BE IN ACCORDANCE WITH THE CURRENT COMPANY FEE SCHEDULE A COPY OF THIS DOCUMENT WILL BE FURNISHED
BY THE SURVEYOR/ENGINEER UPON CLIENT'S REQUEST.
ESTIMATED COMPLETION DATE: 2=3 weeks
In the event that the Surveyor/Engineers obstructed or delayed in the completion at said services by any act of the Client or the Client's agents or try'any act beyond the control of the
Survevov Engineer including,but nat limited to.inclement weather.illness.strikes.tadure at equipment unanticipated degree of difficulty encountered in performing said services.ardeiiy
created mnhimat by approving agencies.then the time herein fixed for the completion at the services shall be extended for a period Of time equivalent of the time lost by.reason of any or all of
the aforementioned causes.
TERMINATION:This Agreement may be terminated by ether party upon five(51 days written notice-n the event of Persistent'auures of performance of material terms and conditions of the
Agreement by the other Darty through nen fault of the terminating party.rhe Surveyor/Engineer shall then oe paid for the services completed up to the time of the termination dated based
upon the above described fee&
OWNERSHIP OF DOCUMENTS:All documents.including original drawing&estimates,specifications. field notes and data are and shall remain the sale and exclusive property of the '
Survevor/Engineer as instruments of service.The Client may,at his expem obtain record prints of drawings.in cdnslderalion,of which!tie Client wdl use them solely m cbnnectior.w-ah the
abovedescnbed protect and not for the purpose of malungsubsequerdestensonscreniargements thereto
AMENDMENT OF AGREEMENT:This Agreement may be amended only in writing signed by the Client and the Surveyor.,Engineer.
APPLICABLE UW:Unless otherwise specified,this Agreement shah be governed by the laws of the Commonwealth of Massachusetts.
SPECIAL INSTRUCTIONS and/or PROVISIONS.,
TERMS:Statements will be rendered at the completion of the work.or monthly.and are due upon Presentation. A FINANCE CHARGE OF to PER MONTHP47PER YEAR)WRL BE
ASD IDU 7-r1 Wi AM B49U.AF ER TMUY-(30) nes EFCM IE DOH(F ME BUIZU0 2JE SUR!MUt Ia� resErves
the rigtLt to terOlmTate.wzark in pvcgtess u;the t ,tpe r
Tt is mt recAaivad in arx rda-m with the paynxIt XcIvisicins.
COLLECTION:The Client agrees to pay all costs of collection.including reasonable attorney's fees.
Tril0eemem Is null and void unless executed by the Client and returned to the Surveyor/Engineer within th y 130 day& Eastern Land Survey
`�/��` Associates , Inc.
Date: Dater
chem a)& Mackey (Company)
by: l - �
A !: Signature _ Christopher R. Mello President
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CITY OF SALEM
, ►q1 CONSERVATION COMMISSION
May 15, 2015
David Mackey
25 Osborne Hill Drive
Salem, MA 01970
Re: Determination of Applicability-25 Osborne Hill Drive
Dear Mr. Mackey:
Enclosed, please find the Determination of Applicability for the above-referenced
property. Work may commence following the 10-business-day appeal period. This
document is effective for three years from its date of issuance.
Please note that the Conservation Commission requests that you consult with the Salem
Building Inspector to ensure that your improvements to the walls are constructed in
accordance with building code.
If you have any further questions please feel free to contact me at 978-619-5685.
Sincerely,
Tom evine
Conservation Agent
Enclosure
CC: DEP Northeast Regional Office
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
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 David Mackey
return key. Name Name
25 Osborne Hill Drive
r� Mailing Address Mailing Address
Salem MA 01970
City/Town State Zip Code City(rown State ip Code
a� 1. Title and Date (or Revised Date if applicable)of Final Plans and Other Documents:
Untitled sketch submitted with 4/28/2015 Request for Determination Undated
Title Date
Title Date
Title Date
2. Date Request Filed:
4/28/2015
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):
New patio, new fence, improvements to stone walls, and expansion of deck.
Project Location:
25 Osborne Hill Drive Salem
Street Address Cityrrown
8 178
Assessors Map/Plat Number Parcel/Lot Number
wpaform2 doc•Determination of Applicability•rev.1214 Page 1 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.)
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) or Order of
Resource Area Delineation (issued following submittal of Simplified Review ANRAD) 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 or ANRAD Simplified Review (if work is limited to the Buffer Zone).
❑ 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
wpaform2.doc•Determination of Applicability•rev.12114 Page 2 of 5'.
L11Massachusetts 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 required by the applicant. However, if the
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.
�j 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.tloc•Determination of Applicability•rev.1214 Page 3 of 5
Massachusetts Department of Environmental Protection
Gt 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)
EgThe area and/or work described in the Request is not subject to review and approval by:
IS,LZ
Pursuan to a municipal wetlands ordinance or bylaw.
Atrf P is t�� S&a34( ca �l a rQ C
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 Dote
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 http://www.mass.gov/eea/agencies/massdel)/about/contacts/)
and the property owner(if different from the applicant).
Signatures:
I �
�r
D
wpaform2.doc•Determination of Applicability•rev.12/14 Page 4 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
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 http://www.mass.gov/eea/agencies/massdep/about/contacts/)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.
wpaform2tloc•Determination of Applicability•rev.12/14 Page 5 of 5
Massachusetts Department of Environmental Protection
t Bureau of Resource Protection - Wetlands DEP File Number:
Request for Departmental Action Fee
Transmittal Form Provided by DEP
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40
A. Request Information
1. Location of Project
a.Street Address b.Cityrrown,Zip
c.Check number d. Fee amount
Important:
When filling 2 Person or party making request(if appropriate, name the citizen group's representative):
out forms on
the computer, Name
use only the
tab key to Mailing Address
move your
cursor-do Cityrrown State Zip Code
not use the
return key. Phone Number Fax Number(if applicable)
3. Applicant(as shown on Determination of Applicability (Form 2), Order of Resource Area Delineation
(Form 4B), Order of Conditions (Form 5), Restoration Order of Conditions(Form 5A), or Notice of
Non-Significance (Form 6)):
Name
Mailing Address
Cityfrown State Zip Code
Phone Number Fax Number(if applicable)
4. DEP File Number:
B. Instructions
1. When the Departmental action request is for(check one):
❑ Superseding Order of Conditions—Fee: $120.00(single family house projects)or$245(all other
projects)
❑ Superseding Determination of Applicability— Fee: $120
❑ Superseding Order of Resource Area Delineation—Fee: $120
Send this form and check or money order, payable to the Commonwealth of Massachusetts, to:
Department of Environmental Protection
Box 4062
Boston, MA 02211
wpaform2.doc•Request for Departmental Action Fee Transmittal Fon•rev.12114 Page 1 of 2
Massachusetts Department of Environmental Protection DEP File Number:
Bureau of Resource Protection - Wetlands
Request for Departmental Action Fee
Transmittal Form Provided by DEP
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40
B. Instructions (cont.)
2. On a separate sheet attached to this form, state clearly and concisely the objections to the
Determination or Order which is being appealed. To the extent that the Determination or Order is
based on a municipal bylaw, and not on the Massachusetts Wetlands Protection Act or regulations,
the Department has no appellate jurisdiction.
3. Send a copy of this form and a copy of the check or money order with the Request for a
Superseding Determination or Order by certified mail or hand delivery to the appropriate DEP
Regional Office (see http://www.mass.gov/eea/agencies/massdep/about/contacts/).
4. 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.
wpaform2.doc•Request for Departmental Action Fee Transmittal Form•rev.1014 Page 2 of 2
ILIMassachusetts 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
A. General Information
Important:
When filling out 1. Applicant:
forms on the David Mackey dtmackey@gmail.com
computer, use Name E-Mail Address
only the tab key
to move your 25 Osborne Hill Drive
cursor-do not Mailing Address
use the return Salem MA 01970
key. City/town State Zip Code
978-578-0167
Phone Number Fax Number(if applicable)
2. 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 Salem 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.
1�A d. whether the area and/or work depicted on plan(s) referenced below is subject to the jurisdiction
r of any municipal wetlands ordinance or bylaw of:
5ak8v m�
Name of Municipality
❑ e. whether the following scope of alternatives is adequate for work in the Riverfront Area as
depicted on referenced plan(s).
wpaformt.doc
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):
ZSbsbcW✓,Q- ONt Dr 5o1 �1ePVN
Street Address City/Town
Assessors Map/Plat Number Parcel/Lot Number
b. Area Description (use additional paper, if necessary): n
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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):
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wpaforml.doc Page 2 of 4
L11Massachusetts 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).
NSA 3. a. If this application is a Request for Determination of Scope of Alternatives for work in the
Riverfront Area, indicate the one classification below that best describes the project.
❑ Single family house on a lot recorded on or before 8/1/96
❑ Single family house on a lot recorded after 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.
IV14 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.)
v for nl.doo Page 3 of 4
ILIMassachusetts Department of Environmental Protection
Bureau of Resource Protection - Wetlands cityrrown
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 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 pro arty owner:
CiVb kL
Name
Mailing Address
Cityrrown
State Zip Code
Signatures:
I also undeE54nd that notification of this Request will be placed in a local newspaper at my expense
in accord ce ith ion 10.05(3)(b)(1)of the Wetlands Protection Act regulations.
`l/Zc/h r
Signature of Applicant Date
Signature of Representative(if any) Date
w atorml.d. Page 4 oro
City of Salem Department of Planning & Community Development
Check/Cash Receipt and Tracking Form
Please complete form and make two copes.
Date Received
Amount Received
Form of Payment
heck 0 Money Order
Client Information
CASH PAYMENTS: client initials
❑ Sign Permit Application Fee
conservation Commission Fee
Payment received for what
service? ❑ Planning Board Fee/ZBA
❑ SRA/DRB Fee
❑ Old Town Hall Rental Fee
❑ Other:
Name of staff person receiving
Payment
Additional Notes.
BLW� SC
SALSET D
E of 8� 5 1
order- e i
8�5
u ynoMuq i
W q1
4k�Fam � date
4C lob
For G
t•O j 30Qo 1 381• Dollars q .,..
ova =Copy 1:
Copy 2: Application , 36 j°'OB 25 lG�
.. eIUE SMEGFIE(Oti
N0l7.j,f
CITY OF SALEM
CONSERVATION COMMISSION
Salem Conservation Commission
978-619-5685
Will hold a public hearing for a Request for Determination of Applicability for David Mackey,
25 Osborne Hill Dr, Salem MA. Purpose of hearing is to discuss proposed new patio and fencing,
deck expansion, and enlargement of existing stone wall at 25 Osborne Hill Dr within an area
subject to protection under the Wetlands Protection Act MGL c.131§40 and Salem Wetlands
Protection & Conservation Ordinance. Hearing will be held 5/14/15 at 6:30pm in the City Hall
Annex, 3rd floor conference room, 120 Washington St.
Please print legal ad on:
May 7, 2015
Please invoice:
David Mackey
25 Osborne Hill Drive
Salem, MA 01970
978-578-0167
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ti � sal,
i ��
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4.
City of Salem Department of Plannin
& Community
Check/Cash Receipt and Tracking Form DeveJOAmens
Please complete form and make
Date Received
° copies.
Amount Re Wed
Form of Payment
'Check
Client Information ❑ Money Order
CASH PAYMENTS: client initials
L�❑�,'CSSiitg�
service? nn Permit Application Fee
Payment received for what v ervation Commission Fee
❑ Planning Board Fee/ZBA
❑ SRA/DR8 Fee
❑ Old Town Hall Rental Fee
❑ Other.
Name of staff person receiving
payment
Additional Notes
824
BRENDA MAMY 53-13/110
MA
2 SUNSET RD (978)741-1511
SALEM,MA 01970 't /
n Dace �
Pay to the �L S 4�vti K�(,J C $
Order of
Dollars
Ba WIo 'W erica
,wH 11,rm,aao,3e I
For �
�:O L 1000 13a': 00460 263 i 16 L11108 24 BLUESEFFeLary �
Origins Wc„�
Copy 1: Client °rm: OPCD Finance
COPY 2: Application File