Loading...
30 WINTER ISLAND ROAD - CONSERVATION COMMISSION (2) � ���� ��w� �� �,�a - � - — -- I Project Status Sheet Address: 3c> �✓`^�`' J7S, DEP # ---� Application Type: Rl� Date Submitted: Contact Name: Dai,( /�'' Phone: 17�p -7'-q od'S �> Proposed activity: X Application Complete Correct Fee Received �-iuum=..� T ict Ra 1„ ♦..�1 j--_ �R�l�' �J Legal Ad Sent Legal Ad Confirmed 90nline J Added to Agenda b Agenda to Applicant bAgent Comments to Commission $DEP Comments Hearing Opened: ��l j Continued: Site Visit: --9-A4wt4t1m Notice Confirmed Order of Conditions Sent to Applicant and DEP ❑ Confirmation of Delivery �Expiration date added to calendar iAdded to database I .Applicant Recorded OoC with Registry Preconstruction Meeting: ❑ Certificate of Compliance Sent to Applicant and DEP ❑ Confirmation of Delivery ❑ Applicant Recorded CoC with Registry Notes: f Massachusetts Department of Environmental Protection ILIBureau of Resource Protection - Wetlands Salem WPA Form 1 - Request for Determination of Applicability Citylrown Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 A. General Information Important: When filling out 1. Applicant: forms on the David Perkins davidperkins55@comcast.net computer, use Name E-Mail Address only the tab key to move your Win30 ter Island Road cursor-do not Mailing Address use the return Salem Mass 01970 key. Citylrown State Zip Code 978 729 0850 +� Phone Number Fax Number(if applicable) 2. Representative (if any): aoy» Firm Contact Name E-Mail Address ® Mailing Address City/Town State Zip Code ON Z W ® y Phone Number Fax Number(if applicable) N 0 F LIJ ¢ Determinations 0 t9. I request the Conservation Commission 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: Salem Mass Name of Municipality ❑ e. whether the following scope of alternatives is adequate for work in the Riverfront Area as depicted on referenced plan(s). wpaforrn Eoc Page 1 of 4 Massachusetts Department of Environmental Protection ILIBureau of Resource Protection -Wetlands Salem 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): 30 Winter Island Road Salem Street Address City/Town Map 44 Lot 29 Assessors Map/Plat Number Parcel/Lot Number b. Area Description (use additional paper, if necessary): The area is a piece of land that is partially located within a buffer zone to a resoure area under the juristriction of the Wetlands Protection Act. The land has a typical residential home located on it with your typical loom, trees, shrubs walkways and asphalt parking. The area of the property boardering the resourse zone has an existing 3' stone wall. 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): Work will include the following; 1. Install approximate 300 sq. ft. patio under existing upper deck and replace 5, 44 posts with columns. This work was approved in 1996 by both the Conservation Commission and the Board of appeals and does not change the footprint of the approved structure. 2. Install approximate 60 sq. ft. platform at main entry of home,create a 5' x 5' glass protected area on the platform and install two decorative pillars. 3. Install approximate 200 sq.ft platform to receive a gazabo. 4. Create walk ways on property from main entrance to front and rear of property 5. Install a fence and trellis on left side of home 6. Remove existing asphalt driveway where located and install a paver drive way at the front of the property and side of house. 7. Locate a shed approximatey 144 sq.ft. in size on property. All structures will be made of stone with appropriate surface preparation leveling. Existing grade maintained with leveling where required. Property is located in Flood Zone B evidenced by the elevation certificate ,aerial view and a rough draft rendering of landscape design of property are included as attachments to the application. wpaformt.doe Page 2 of 4 r Massachusetts Department of Environmental Protection ILIBureau of Resource Protection - Wetlands Salem WPA FOrm 1 - Request for Determination of Applicability City/Town Massachusetts 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). & 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. 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.doc Page 3 of 4 i f Massachusetts Department of Environmental Protection Bureau of Resource Protection -Wetlands Salem 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 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: David Perkins Name 30 Winter Island Road Mailing Address Salem Cityrrown Mass 01970 State Zip Code Signatures: I also understand that notificati of this Request will be placed in a local newspaper at my expense in,! cord ce with Secon 05 (b)(1)of the Wetlands Protection Act regulations. Si na ure of Applicant Date Signature of Representative(if any) Date wpaforml.doc Page 4 of 4 . ��'Ap� k�+t> 9 i aµ 1 "• :�° �Y� ° lir 's-'`v`� !N � A Ir y -- - ' s.`k• k ' rye .: . i-, Interactive Map -45 t 4 s? r ! y .qk-t ��yy ♦{ _ lit �ti E -t,�a �M' r \t� '�• r � ,ar. Property Infornnation Property ID Location MAP FOR REFERENCE ONLY NOT DOCUMENT ^ David Perkins �,, ' 30 Winter Island Rd t�_ ""•`w� "•,� /' Salem,MA 01970-5731 .i_ taW '�i1 fj Yew hedge r Off . o Pa n r • _,�.P i l�,.n•, rzFi 3 1` ai ,yx n { Drain f U.S.DEPARTMENT OF HOMELAND SECURITY ELEVATION CERTIFICATE OMB No. 1660-0008 Federal Emergency Management Agency Expires March 31,2012 National Flood Insurance Program Important: Readthe instructions on pages'1-9. SECTION A-PROPERTY INFORMATION for;=Insurance Company Use h Al. Building Owners Name David Perkins Pokey Number A2. Building Street Address(inducting Apt.,Unit,Suite,and/or Bldg;No.)or P.O.Route and Box No. Coltipa-fiy NAIC Number' ..` 30 Winter Island Road ,,,,. ,( City Salem State MA ZIP Code 01971 `�` A3. Property Description(Lot and Block Numbers,Tax Parcel Number,Legal Descnptior,etc:) Assessors Map 44,Lot 29 A4. Building Use(e.g.,Residential,Non-Residential,Addition,Accessory,etc.)Residential A5: Latitude/Longitude:Lat._ Long._ Horizontal Datum: ® NAD 1927 ❑ NAD 1983 A6. Attach at least 2 photographs of the buildingif the Certificate is being used to obtain flood insurance. A7. Building Diagram Number 1 A8. For a building with a crawlspaceor enclosure(s): 1 A9. For atluilding with an attached garage: a) Square footage of crawlspace or enclosure(s) n/a i I sq ft a) Square footage of attached garage 500 sq It b) No.of permanent flood openings in the crawlspace or i enclosure(s)within 1.0 foot above adjacent grade n b) No.of permanent flood openings foot above adjacent 1 ithe attached garage within pe C) Total net area of flood openings in AB.b sq in c) Total net area of flood openings in A9.b 24 sq in d) Engineered flood openings? El Yes ❑ No d) Engineered flood openings? ❑ Yes ® No SECTION B-FLOOD INSURANCE RATE MAP(FIRM)INFORMATION 81.NFIP Community Name&Community Number B2.County Name B3.State Salem Essex MA B4.Map/Panel Number B5.Suffix B6.FIRM Index 87.FIRM Panel B8.Flood B9.Base Flood Elevation(s)(Zone 250102 026 Date I. Effective/Revised Date Zone(s) AO,use base flood depth) 8/5/85 1 B 10 B10. Indicate the sourceofthe Base Flood Elevation(BFE)data or base flood depth entered in Item B9.. ❑ FIS Profile ® FIRM ❑ Community Determined. ❑ Other(Describe)_ B11. Indicate elevation datum used for BFE in Item B9: ® NGVD 1929 ❑ NAVD 1988 ❑ Other(Describe)_ B12. Is the building located in a Coastal Barrier Resources System(CBRS)area or Otherwise Protected Area(OPA)? ❑ Yes ® No Designation Dale ❑i CBRS ❑ OPA SECTION C-BUILDING ELEVATION INFORMATION(SURVEY REQUIRED) Cl. Building elevations are based on: ❑ Construction Drawing's' ❑ Building Under Construction` ® Finished Construction 'A new Elevation Certificate will be required when construction of the building is complete. C2. Elevations—Zones A7-A30,AE,AH,A(with<BFE);VE,V1 V30,V(with BFE),AR,ARIA,ARAE,AR/A1-A30,.AR/AH,AR/AD. Complete Items C2.a-h below according to the building diagram specified in Item A7. Use iihe same datum as the BFE. Benchmark Utilized RMBVertical Datum 1929 Conversion/Comments_ Check the measurement used. a) Top of bottom floor(including basement,crawlspace,or enclosure floor)11.1. ®feet E]meters(Puerto Rice only) b): Top of the nett higher floor 21.1 ®-feet ❑meters(Puerto Rico only) c) Bottom of the lowesthorizontal structural member(V Zones only) __ ❑feet [:1 meters(Puerto Rica only) d) Attached garage(top of slab) 11.1 :®feet ❑meters(Puerto Rico only) e) Lowest elevation of machinery or equipment servicing the building 11..1 ®feet ❑meters(Puerto Rico only) (Describe type of equipment and location in Comments) i) Lowest adjacent(finished)grade next to building(LAG) 10:8 ®feet ❑meters(Puerto.Rim only) g) Highest adjacent(finished)grade next to building(HAG) 11.1 ®feet ❑meters(Puerto Rico only) h) Lowest adjacent grade at lowest elevation of deck or stairs,including 10.8 ®feet ❑meters(Puerto Rico only) structural support SECTION D-SURVEYOR, ENGINEER,OR ARCHITECT CERTIFICATION This certification is to be signed and sealed by a land surveyor,engineer,or architect authorized by law to certify elevation _ information. I certify that the information on this Certificate represents my best efforts to interpret the data available./ understand that any false statement maybe punishable by fine or imprisonment under 18 U.S Code, Section 1001.[] Check here if commentsam.provided on back of form. Werellatitude andlongitude in Section A provided by a >rt7, licensed land surveyor? El Yes ® No 01,, .1, -0ertifiers Name John P.Judd i License Number 38360 k� 3 ➢_;: r; Title Engineer Company Name Gateway Consultants,Ina Address 33 Forest Hill Ave C'qty L nnfield Y State MA. ZIP Code 01940 Signature Date Telephone FEMA.Form 81-3t,Mar 09 Seereverse side for continuation. Replaces all previous editions City of Salem Department of Planning & Community Development Check/Cash Receipt and Tracking Form Please complete form and make two copies. Date Received 211— Amount Received ra — Form of Payment 4�-Check ❑ Cash Client [information CASH PAYMENTS: client initials ] Sign Permit Application Fee ®"Conservation Commission Fee Planning Board Fee/ ZBA t Payment received for what service? ❑ SRA/DRB Fee El Copies Other: Name of staff person receiving payment Additional Notes i i. DAVIDPERKINS 11/02 1139 30 WINTERR ISLANDSLAND ROAD S701712110 SALEM,MA 01970 - ' a c.' i L tae Date - ..Pay to the - - .. $- order of _ 7G� Dollars Cit zens Circle Account i -Citizens Bank �/�j Massachusettsrw-=— /� For i 1: 211070175': 113730589111' ii39 I Original Chick and Form: I)PCD 1-in,wc Cally L: i L tit Cutty Z: %imi.,'.it"?,] Fdd I e 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 and mail immediately to SALEM NEWS Attention Gloria Pobiedzinski 32 DUNHAM ROAD BEVERLY,MA 01915 **Average legal notice costs are estimated "Customer will either be refunded or billed when the legal notice is published Salem News=$250.00 per day Check# Credit Card please call Gloria @ the Salem News 978-338-2512 If payment is not received the Legal Notice will be cancelled 4)-01 6?Ia�' Signed Applicant/Authorized Agent Date Print Name__)[ V I Y r% Address �6 ll(1 of TyY� LA\f n /2(p 5 - Vn.jq-330 l9 1 u Phone 32 DUNHAM ROAD ADVERTISING FAX 978.922-4330 BEVERLY, MA 01915.1895 NEWSROOM FAX 878-927-4524 TELEPHONE 978-922-1234 - E-MAIL ECNNEW9.COM f CITY OF SALEM CONSERVATION COMMISSION September 17, 2012 David Perkins 30 Winter Island Road Salem, MA 01970 Re: Determination of Applicability-30 Winter Island Road, Salem, MA Dear Mr. Perkins: Enclosed, please find the determination of applicability for the above-referenced property. Please be advised that work must comply with the following special conditions issued by the Conservation Commission. 1. Adequate erosion controls must be installed at the wall opening at the seaward side of the yard. 2. The patio and substructure of the gazebo must be constructed using pervious pavers. 3. If applicable, building permits must be obtained from the City of Salem's Inspectional Services Department. A copy of any plans submitted to the Inspectional Services Department must also be submitted to the Conservation Commission. 4. The location of the gazebo must comply with any applicable setback requirements per the City of Salem Zoning Ordinance. This document is effective for three years from its date of issuance. If you have any further questions please feel free to contact me at 978-619-5685. Sincerely, / Tom D2vine Conservation Agent/Staff Planner Enclosure CC: DEP Northeast Regional Office jjyy Ste'. .. 64 Massachusetts Department of Environmental Protection i 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 computer, use Salem only the tab Conservation Commission I key to move To: Applicant Your cursor- Property Owner (if different from applicant): do not use the David Perkins return key. Name Nam ----------- =y rad 30 WinterIsland Road Mailing Address Mailing Address ----"--- -- Salem MA 01970 city/Town State ------ 'eRO' ZIP City/Town ----- - State Zip Code 1. Title and Date (or Revised Date if applicable) of Final Plans and Other Documents: Untitled plan submitted with 8/27/2012 Request for Determination title — Undated Dale Title Dale . . . . - .. Title 2. Date Request Filed: Date 8/27/2012 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): Construction of new vestibule, patio, gazebo, fence, trellis, and walking paths within buffer zone to a wetland resource area. Project Location: 30 Winter Island Road Street Address — --- Salem _ 44 City/Town --_- -- . . Assessors Map/Plat 29um__ Parcel/Lot Nber - wpaform2.doc•Delerminabon of Applicabilily•rev.10/6104 r'JW 1 of Massachusetts Department of Environmental Protection r Bureau of Resource Protection - Wetlands WPA Form 2 — Determination of Applicability Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 t5 B. Determination The following Determination(s) is/are applicable to the proposed site and/or Protection Act and regulations: project relative to the Wetlands Positive Determination t Note: No work within the jurisdiction of the Wetlands Protection Act may Conditions (issued following submittal of a Notice of Intent or Abbreviated Notice of Itnitenft)or Order of 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 wort; 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 revievv and approval by: Name of Municipality - Pursuant to the following municipal wetland ordinance or bylaw: Name _— Ordinance or Bylaw Citation wpaform2.boc-Determination of Applicabilily•rev.1016104 'age2olh �. #T t. Massachusetts Department of Environmental Protection a Bureau of Resource Protection - Wetlands WPA Form 2 — Determination of Applicability Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 M 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 tfo- 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 proceeo 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 documaml ❑ 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 vii 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 theling offf a N�ge 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. wparprm2.tlee Delerminalion of Applicabilily-rev.10/6/04 f 4./ Massachusetts Department of Environmental Protection g ice— Bureau of Resource Protection - Wetlands I,\ 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 U;e Act and the regulations, no Notice of Intent is required: Exempt Activity(site applicable statua—t /regulatory provision— s�----------- - ® 6. The area and/or work described in the Request is not subject to review and approval by Salem Nameof Municipality Pursuant to a municipal wetlands ordinance or bylaw. Wetlands Protection and Conservation Name _ c.5_0 Ordinance or Bylaw Cilation L,. Authorization — This Determination is issued to the applicant and delivered as follows: ❑ by hand delivery on by certified mail, return receipt regl.lesled o 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 h ://www.mass. ov/d about/re ion.fir��cdiypur.lrn.) and the property owner(if different from the applicant). fr '17 —� -- --- Date ------ wpaform2rloc Delennination of Applkabiliiy-rev.10/6/04 (b:H n ci i ' r t 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 and is located, are hereby notified of their right to request the appropriate Department of Environmental Protection Regional Office (see h.tti2:liwww.inass.gov/dep/about/regioil.filidyotir.htni) 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 clays 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 tloc-Determination of Applicability•rev-1016104 Puy:5 of- Massachusetts Department of Environmental Protection ? Bureau of Resource Protection - Wetlands a Request for Departmental Action Fee Transmittal Form Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 A. Request Information - -- - Important: When filling out 1. Person or party making request (if appropriate, name the citizen group's representative): forms on the computer, use Name ------ only the tab key to move your Cursor- Mailing Address - - do not use the return key. City/Town -- --- --- State Zip Code f' "d PhoneNumber Fax Number(if applicable) r, Project Location _ City/Town -------_---- - ._. - Slate Zip Code 2. Applicant (as shown on Notice of Intent (Form 3), Abbreviated Notice of Resource Area Delineation (Form 4A); or Request for Determination of Applicability (Form 1)): NameN/1—. — ailing Address — City/Town - - -- State Zip Code Phone Number Fax Number(if applicable) 3. DEP File Number: B. Instructions - 1. When the Departmental action request is for (check one): ❑ Superseding Order of Conditions ($100 for individual single family homes with associated structures; $200 for all other projects) ❑ Superseding Determination of Applicability($100) ❑ Superseding Order of Resource Area Delineation ($100) Send this form and check or money order for the appropriate amount, payable to the Commonwealth of Massachusetts to: Department of Environmental Protection Box 4062 Boston, MA 02211 ,vpoerm2 Aoc•Request for Departmental Action Fee Transmittal Form•rev. 1016104 Paq? I of. i E F Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands Request for Departmental Action Fee Transmittal Form 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 Supei sedinc Determination or Order by certified mail or hand delivery to the appropriate DEP Regional Office (see http://www.mass.gov/dep/about/region/findyour.htm). 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. .vpalorm2 doc-Request for Departmental Action Fee Transmittal Form•rev.1016104 Poge 2 pf_