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11A-070D east center street conservationOW-5 • Massachusetts Department of Environmental Protection Bureau of Resource Protection — Wetlands WPA Form 1- Request for Determination of Applicability Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 City of Northampton Wetlands Protection Ordinance, c. 24 City/Town Northampton E -Mail Address (if applicable) A# U`dS State Zip Code 5 9'6 -��,�� Fax Number (If applicable) / 1 E-Mail Address (if applicable) D /Wil State Zip Code Fax Number (If applicable) B. Determinations 1. I request the Northampton Conservation Commission make the following determination(s). Check any that a ply: 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. F 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 Northampton. ❑ e. whether the following scope of alternatives is adequate for work in the Riverfront Area as depicted on referenced plan(s). Note: The Northampton Conservation Commission requires a total of nine (9) collated copies of this application when it is submitted, together with the $50.00 filing fee. WPA F0=1 Rev. Q= Paget of 4 A. General Information Important: When filling out 1. Applicant: forms the S I,�S Q - ' t ) t'v v N to computer use only the tab key Name J C - S �' . „ C� C e, to move your cursor - do not use the return Mailing Address kce key. City/Town 41. SQL �Lh Phone Number 2. Representative (if any): P " &VS Gh VIeV -, o ,14C Fm, New A,, Contact Name Mailing Address City/ Town J Phone Number City/Town Northampton E -Mail Address (if applicable) A# U`dS State Zip Code 5 9'6 -��,�� Fax Number (If applicable) / 1 E-Mail Address (if applicable) D /Wil State Zip Code Fax Number (If applicable) B. Determinations 1. I request the Northampton Conservation Commission make the following determination(s). Check any that a ply: 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. F 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 Northampton. ❑ e. whether the following scope of alternatives is adequate for work in the Riverfront Area as depicted on referenced plan(s). Note: The Northampton Conservation Commission requires a total of nine (9) collated copies of this application when it is submitted, together with the $50.00 filing fee. WPA F0=1 Rev. Q= Paget of 4 Massachusetts Department of Environmental Protection Bureau of Resource Protection — Wetlands WPA Form 1- Request for Determination of Applicability Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 City of Northampton Wetlands Protection Ordinance, c. 24 C. Project Description 1. a. Project Location (use maps and plans to identify the location of the area subject to this request): S3 C. Northampton Street Address City/ Town fla ©70 -00/ Assessors Map /Plat Number (REQUIRED) Paroel/Lot Number (REQUIRED) b. Area Description (use additional paper, if necessary): .See, tow c. Plan and /or Map Reference(s): s; k P 1't" Avtp Ot-LC&Kd Title k1111v3 / / Date 2. a. Work Description (use additional paper and /or provide plan(s) of work, if necessary): (• �'� 1'a Ar+. l%ou11 2,#16 d 0 l fi 16 AL*4 fh�9 I v rew -OV�C df IhuRs ►� At �,.��,�s,a�h•�- ho rj l Lo &loj & �O .SG t 0 t Cons kt—m►i e P67 o �. 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). (� (/M�h>r� � ►i/�f - �.c.a� J' 1� n,..� «- �nxr -. � �w�-- � S, � �i WPA Fam1 Rev. 04100 Page Z of 4 Massachusetts Department of Environmental Protection Bureau of Resource Protection — Wetlands WPA Form 1- Request for Determination of Applicability Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 City of Northampton Wetlands Protection Ordinance, c. 24 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 Appendix A) 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: Name Mailing Address Cityfrown State Signatures: 1 53 G. G h- h eels Zip Code I also understand that notification of this Request will be placed in a local newspaper in accordance with Section 10.05(3)(b)(1) of the Wetlands Protection Act regulations and that the $50.00 filing fee includes this cost. s n d' 3'10.3 Signature of Applicant "Date Signature of Representative (if any) Date Affidavit of Service Under the Northampton Wetlands Protection Ordinance when filing a Request for Determination of Applicability the following action is required: I' (name of person making the Affidavit) hereby certify under the pains and of perjury, that on /by (insert date) I posted a sign on the property (facing the public- right -of -way) at least 5 days prior to the public hearing stating that Request for Determination is pending with the Northampton Conservation Commission and indicating where additional information can be obtained. WPA Fount Rev. MM Page 4 of 4