permit noho RDA both properties 7-26-23.pdfwpaform1.doc • rev. 4/28/2023 WPA Form 1 – Request for Determination of Applicability • Page 1 of 3
Massachusetts Department of Environmental Protection Bureau of Water Resources - Wetlands WPA Form 1- Request for Determination of Applicability
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Municipality
A.General Information
Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key.
1.Applicant:
First Name Last Name
Address
City/Town State Zip Code
Phone Number Email Address
2.Property Owner (if different from Applicant):
First Name Last Name
Address
City/Town State Zip Code
Phone Number Email Address (if known)
3.Representative (if any)
First Name Last Name
Company Name
Address
City/Town State Zip Code
Phone Number Email Address (if known)
B.Project Description
1.a. Project Location (use maps and plans to identify the location of the area subject to this request):
Street Address City/Town
How to find Latitude and Longitude Latitude (Decimal Degrees Format with 5 digits after
42.340286
72.651701
and how to convert to decimal degrees Assessors’ Map Number Assessors’ Lot/Parcel Number
b.Area Description (use additional paper, if necessary):
c.Plan and/or Map Reference(s): (use additional paper if necessary)
Title Date
Title Date
wpaform1.doc • rev. 4/28/2023 WPA Form 1 – Request for Determination of Applicability • Page 2 of 3
Massachusetts Department of Environmental Protection Bureau of Water Resources - Wetlands WPA Form 1- Request for Determination of Applicability
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Municipality
B.Project Description (cont.)
2.a. Activity/Work Description (use additional paper and/or provide plan(s) of Activity, if necessary):
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, ifnecessary).
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.
b.Provide evidence (e.g., record of date subdivision lot was recorded) supporting the classificationabove (use additional paper and/or attach appropriate documents, if necessary.)
wpaform1.doc • rev. 4/28/2023 WPA Form 1 – Request for Determination of Applicability • Page 3 of 3
Massachusetts Department of Environmental Protection Bureau of Water Resources - Wetlands WPA Form 1- Request for Determination of Applicability
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Municipality
C.Determinations
1.I request the
Conservation Commission
make the following determination(s). Check any that apply:
a. whether the area depicted on plan(s) and/or map(s) referenced above is an area subject tojurisdiction of the Wetlands Protection Act.
b. whether the boundaries of resource area(s) depicted on plan(s) and/or map(s) referenced
above are accurately delineated.
c.whether the Activities depicted on plan(s) referenced above is subject to the WetlandsProtection Act and its regulations.
d. whether the area and/or Activities depicted on plan(s) referenced above is subject to the
jurisdiction of any municipal wetlands’ ordinance or bylaw of:
Name of Municipality
e. whether the following scope of alternatives is adequate for Activities in the Riverfront Area asdepicted on referenced plan(s).
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.
Signatures:
I also understand that notification of this Request will be placed in a local newspaper at my expense
in accordance with Section 10.05(3)(b)(1) of the Wetlands Protection Act regulations.
Signature of Applicant Date
Signature of Representative (if any) Date