Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
Miscellaneous - 35 WRIGHT AVENUE
Massachusetts Department of Environmental Protection Bureau of Resource Protection -Wetlands DEP File Number: L11 WPA Form 8B - Certificate of Compliance 242-1292 Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Provided by DEP A. Project Information Important: When filling out 1. This Certificate of Compliance is issued to: forms on the Susan Hansen computer, use only the tab Name key to move 35 Wright Avenue your cursor- Mailing Address do not use the North Andover MA. 01845 return key. City/Town State Zip Code aiTl,� I I 2. This Certificate of Compliance is issued for work regulated by a final Order of Conditions issued to: Susan Hansen Name 2/2/05 242-1292 Dated DEP File Number 3. The project site is located at: 35 Wright Avenue North Andover Street Address Cityfrown Map 73 Parcel 73 Assessors Map/Plat Number Parcel/Lot Number the final Order of Condition was recorded at the Registry of Deeds for: Same Property Owner(if different) Essex North Docket#8224 on 3/10/05 County Book Page Certificate 4. A site inspection was made in the presence of the applicant, or the applicant's agent, on: 9/8/05 Date B. Certification Check all that apply: ® Complete Certification: It is hereby certified that the work regulated by the above-referenced Order of Conditions has been satisfactorily completed. ❑ Partial Certification: Itis hereby certified that only the following portions of work regulated by the above-referenced Order of Conditions have been satisfactorily completed.The project areas or work subject to this partial certification that have been completed and are released from this Order are: wpaform 8b.doc•rev.7113/04 Page 1 of 4 Massachusetts Department of Environmental Protection Bureau of Resource Protection -Wetlands DEP File Number. WPA Form 8B — Certificate of Compliance Massachusetts Wetlands Protection Act M.G.L. c. 131+ � Provided 40 24vb Provided by DEP B. Certification (cont.) ❑ Invalid Order of Conditions: It is hereby certified that the work regulated by the above-referenced Order of Conditions never commenced. The Order of Conditions has lapsed and is therefore no longer valid. No future work subject to regulation under the Wetlands Protection Act may commence without filing a new Notice of Intent and receiving a new Order of Conditions. ® Ongoing Conditions: The following conditions of the Order shall continue: (Include any conditions contained in the Final Order, such as maintenance or monitoring, that should continue for a longer period). Condition Numbers: 69 C. Authorization Issued by: North Andover Conservation Commission Date dissuince This Certificate must be signed by a majority of the Conservation Commission and a_copy sent to the applicant and appropriate DEP Regional Office (See Attach nt). n Signatures: rdt 11 wpaform Bb.doc-rev.7/13/04 Page 2 of 4 L11Massachusetts Department of Environmental Protection Bureau of Resource Protection- Wetlands DEP File Number: WPA Form 8B — Certificate of Compliance 242-1292 Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Provided by DEP C. Authorization (cont.) Notary Acknowledgement Commonwealth of Massachusetts County of Essex North Day t� 4 a©oS On this pOf Month Year before me, the undersigned Notary Public, personally appeared s"C�o++ R"sem Name of Document Signer proved to me through satisfactory evidence of identification, which was/were Massachusetts License Description of evidence of identification to be the person whose name is signed on the preceding or attached document, and acknowledged to me that he/she signed it voluntarily for its stated purpose. As member of North Andover Conservation Commission City/Town J / y Signature of Notary Public DO/7011 M. DONNA M.WEDGE Printed Name of Notary Public NOTARY PUBLIC COMMONWEALTH OF MASSACHUSETTS My Comm.Expires Aug.7,2009 S' s7 a0o 9 My C ission E pires(Date) Place notary seal and/or any stamp above Si ure of Notary Public wpaform Bb.doc-rev.7/13104 Page 3 of 4 Massachusetts Department of Environmental Protection Bureau of Resource Protection -Wetlands DEP File Number: WPA Form 8B — Certificate of Compliance Massachusetts Wetlands Protection Act M.G.L. c. 131, 40 242-1292 Provided by DEP D. Recording Confirmation The applicant is responsible for ensuring that this Certificate of Compliance is recorded in the Registry of Deeds or the Land Court for the district in which the land is located. Detach on dotted line and submit to the Conservation Commission. To: North Andover Conservation Commission Please be advised that the Certificate of Compliance for the project at: 242-1292 Project Location DEP File Number Has been recorded at the Registry of Deeds of. County for: Property Owner and has been noted in the chain of title of the affected property on: Date Book Page If recorded land, the instrument number which identifies this transaction is: If registered land,the document number which identifies this transaction is: Document Number Signature of Applicant wpaform 8b.doc•rev.7/13/04 Page 4 of 4 Massachusetts Department of Environmental Protection Bureau of Resource Protection -Wetlands DEP Regional Addresses Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Mail transmittal forms and DEP payments,payable to: Commonwealth of Massachusetts Department of Environmental Protection Box 4062 Boston, MA 02211 DEP Western Region Adams Colrain Hampden Monroe Pittsfield Tyringham 436 Dwight Street Agawam Conway Hancock Montague Plainfield wales Alford Cummington Hatfield Monterey Richmond Ware Suite 402 Amherst Dalton Hawley Montgomery Rowe Warwick Springfield,MA 01103 Ashfield Deerfield Heath Monson Russell Washington Phone:413-784-1100 Becket Easthampton Hinsdale Mount Washington Sandisfield Wendell 8elchertown East Longmeadow Holland New Ashford Savoy Westfield Fax:413-784-1149 Bemardston Egremont Holyoke New Marlborough Sheffield Westhampton Blandford Erving Huntington New Salem Shelburne West Springfield Brimfield Florida Lanesborough North Adams Shutesbury West Stockbridge Buckland Gill Lee Northampton Southampton Whately Charlemont Goshen Lenox Northfield South Hadley Wilbraham Cheshire Granby Leverett Orange Southwick Williamsburg Chester Granville Leyden Otis Springfield Williamstown Chesterfield Great Barrington Longmeadow Palmer Stockbridge Windsor Chicopee Greenfield Ludlow Pelham Sunderland Worthington Clarksburg Hadley Middlefield Peru Tolland DEP Central Region Acton Charlton Hopkinton Millbury Rutland Uxbridge 627 Main Street Ashburnham Clinton Hubbardston Millville Shirley Warren Ashby Douglas Hudson New Braintree Shrewsbury Webster Worcester,MA 01608 Athol Dudley Holliston Northborough Southborough Westborough Phone:508-792-7650 Auburn Dunstable Lancaster Northbridge Southbridge West Boylston Fax:508-792-7621 Ayer East Brookfield Leicester North Brookfield Spencer West Brookfield Barre Fitchburg Leominster Oakham Sterling Westford TDD:508-767-2788 Bellingham Gardner Littleton Oxford Stow Westminster Berlin Grafton Lunenburg Paxton Sturbridge Winchendon Blackstone Groton Marlborough Pepperell Sutton Worcester Bolton Harvard Maynard Petersham Templeton Boxborough Hardwick Medway Phillipston Townsend Boylston Holden Mendon Princeton Tyngsborough Brookfield Hopedale Milford Royalston Upton DEP Southeast Region Abington Dartmouth Freetown Mattapoiselt Provincetown Tisbury 20 Riverside Drive Acushnet Dennis Gay Head Middleborough Raynham Truro Attleboro Dighton Gosnold Nantucket Rehoboth Wareham Lakeville,MA 02347 Avon Duxbury Halifax New Bedford Rochester Wellfleet Phone:508-946-2700 Barnstable Eastham Hanover North Attleborough Rockland West Bridgewater Fax: 508-947-6557 Berkley East Bridgewater Hanson Norton Sandwich Westport Bourne Easton Harwich Norwell Scituate West Tisbury TDD:508-946-2795 Brewster Edgartown Kingston Oak Bluffs Seekonk Whitman Bridgewater Fairhaven Lakeville Orleans Sharon Wrentham Brockton Fall River Mansfield Pembroke Somerset Yarmouth Carver Falmouth Marion Plainville Stoughton Chatham Foxborough Marshfield Plymouth Swansea Chilmark Franklin Mashpee Plympton Taunton DEP Northeast Region Arnesbury Chelmsford Hingham Merrimac Quincy Wakefield 1 Winter Street Andover Chelsea Holbrook Methuen Randolph Walpole Arlington Cohasset Hull Middleton Reading Waltham Boston,MA 02108 Ashland Concord Ipswich Millis Revere Watertown Phone:617-654-6500 Bedford Danvers Lawrence Milton Rockport Wayland Fax: 617-556-1049 Belmont Dedham Lexington Nahant Rowley Wellesley Beverly Dover Lincoln Natick Salem Wenham TDD:617-574-6868 Billerica Dracut Lowell Needham Salisbury West Newbury Boston Essex Lynn Newbury Saugus Weston Boxford Everett Lynnfield Newburyport Sherbom Westwood Braintree Framingham Malden Newton Somerville Weymouth Brookline Georgetown Manchester-By-The-Sea Norfolk Stoneham Wilmington Burlington Gloucester Marblehead North Andover Sudbury Winchester Cambridge Groveland Medfield North Reading Swampscott Winthrop Canton Hamilton Medford Norwood Tewksbury Woburn Carlisle Haverhill Melrose Peabody Topsfield wpaform6b.doc•DEP Addresses•rev.9/8/05 Page 1 of 1 Y Massachusetts Department of Environmental Protection 1 � Bureau of Resource Protection - Wetlands DEP File Number: WPA Form 5 - Order of Conditions 242-1292 Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 A. General Information Important: North Andover When filling From: 1.Conservation Commission out forms on the computer, 2. This issuance is for(check one): Z Order of Conditions ❑ Amended Order of Conditions use only the tab key to 3. To: Applicant: move your cursor-do not Susan Hansen use the return a.First Name b.Last Name c.Company key. 35 Wright Avenue d.Mailing Address rQ North Andover MA. 01845 e.City/Town f.State g.Zip Code 4. Property Owner(if different from applicant): a. First Name b.Last Name c.Company d.Mailing Address e.City/Town f.State g.Zip Code 5. Project Location: 35 Wright Avenue North Andover a.Street Address b.City/Town Map 73 Lot 73 c.Assessors Map/Plat Number d.Parcel/Lot Number Latitude and Longitude, if known(note: electronic filers will click for GIS locator): e. Latitude f.Longitude s. Property recorded at the Registry of Deeds for(attach additional information if more than one parcel): Essex North a.County b.Certificate(if registered land) 8374 22 c. Book d.Page 12/22/04 1 h A ks 7. Dates: a.Date Notice of Intent Filed b.Date FfublicHearing Closed c.Date of Is uance 8. Final Approved Plans and Other Documents(attach additional plan or document references as needed): Site Plan a. Plan Title New England Engineering Services, Inc. Benjamin C. Osgood, Jr., P. E. b. Prepared By c.Signed and Stamped by 12/22/04 d.Final Revision Date e.Scale f.Additional Plan or Document Title g.Date 9. Total WPA Fee Paid: $215.00 a.Total Fee Paid b.State Fee Paid c.City/Town Fee Paid IIS wpaform5.dcc• rev.1/10/05 Page 1 of 9 { Massachusetts Department of Environmental Protection 7L,; Bureau of Resource Protection - WetlandsDEP File Number: J� WPA Form 5 Order of Conditions 242-1292 Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 B. Findings 1. Findings pursuant to the Massachusetts Wetlands Protection Act: Following the review of the above-referenced Notice of intent and based on the information provided in this application and presented at the public hearing, this Commission finds that the areas in which work is proposed is significant to the following interests of the Wetlands Protection Act. Check all that apply: a. ® Public Water Supply b. ❑ Land Containing Shellfish c. ® Prevention of Pollution d. ® Private Water Supply e. ❑ Fisheries f. ® Protection of Wildlife Habitat g. ® Groundwater Supply h. ® Storm Damage Prevention i. ® Flood Control 2. This Commission hereby finds the project,as proposed, is: (check one of the following boxes) Approved subject to: ® the following conditions which are necessary in accordance with the performance standards set forth in the wetlands regulations. This Commission orders that all work shall be performed in accordance with the Notice of Intent referenced above, the following General Conditions, and any other special conditions attached to this Order. To the extent that the following conditions modify or differ from the plans, specifications, or other proposals submitted with the Notice of Intent, these conditions shall control. Denied because: ❑ the proposed work cannot be conditioned to meet the performance standards set forth in the wetland regulations. Therefore, work on this project may not go forward unless and until a new Notice of Intent is submitted which provides measures which are adequate to protect these interests, and a final Order of Conditions is issued. A description of the performance standards which the proposed work cannot meet is attached to this Order. ❑ the information submitted by the applicant is not sufficient to describe the site, the work, or the effect of the work on the interests identified in the Wetlands Protection Act. Therefore, work on this project may not go forward unless and until a revised Notice of Intent is submitted which provides sufficient information and includes measures which are adequate to protect the Act's interests, and a final Order of Conditions is issued.A description of the specific information which is lacking and why it is necessary is attached to this Order as per 310 CMR 10.05(6)(c). Inland Resource Area Impacts: Check all that apply below. (For Approvals Only) Resource Area Proposed Permitted Proposed Permitted Alteration Alteration Replacement Replacement 3. ❑ Bank a.linear feet b.linear feet c.linear feet d. linear feet 4. ❑ Bordering Vegetated Wetland a.square feet b.square feet c.square feet d.square feet 5. ❑ Land Under a.square feet b.square feet c.square feet d.square feet Waterbodies and Waterways e.cu.yd dredged f.cu.yd dredged I wpafcrm5.doc- rev.1110105 Page 2 of 9 r Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands DEP File Number: WPA Form 5 - Order of Conditions 242-1292 Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 B. Findings (cont.) Resource Area Proposed Permitted Proposed Permitted Alteration Alteration Replacement Replacement 6. ❑ Bordering Land Subject to Flooding a.square feet b.square feet c.square feet d.square feet Cubic Feet Flood Storage e.cubic feet f.cubic feet g.cubic feet h.cubic feet 7. ❑ Isolated Land Subject to Flooding a.square feet b.square fleet Cubic Feet Flood Storage c.cubic feet d.cubic feet e.cubic feet f.cubic feet 8. ❑ Riverfront area a.total sq.feet b.total sq.feet Sq ft within 100 ft c.square feet d.square feet Sq ft between 100-200 ft e.square feet f.square feet Coastal Resource Area Impacts: Check all that apply below. (For Approvals Only) s. ❑ Designated Port Indicate size under Land Under the Ocean, below Areas 1o. ❑ Land Under the Ocean a.square feet b.square feet c.cu.yd dredged d.cu.yd dredged 11. ❑ Barrier Beaches Indicate size under Coastal Beaches and/or Coastal Dunes below 12. ❑ Coastal Beaches a.square feet b.square feet c.cly nourishmt, d.c/y nourishmt. 13. ❑ Coastal Dunes a.square feet b.square feet c.c/y nourishmt. d.c/y nourishmt 14. ❑ Coastal Banks a.linear feet b.linear feet 15. ❑ Rocky Intertidal Shores a.square feet b.square feet 16. ❑ Salt Marshes a.square feet b.square feet c.square feet d.square feet 17. ❑ Land Under Salt Ponds a.square feet b.square feet c.cu.yd dredged d.cu.yd dredged 18. ❑ Land Containing Shellfish a.square feet b.square feet c.square feet d.square feet 19. ❑ Fish Runs Indicate size under Coastal Banks, inland Bank, Land Under the Ocean, and/or inland Land Under Waterbodies and Waterways, above a. cu.yd cu.yd dredged b. dredged Y 9 Y 9 20. ❑ Land Subject to Coastal Storm Flowage a.square feet b.square feet wpaform5.doc• rev.1/10/05 Page 3 of 9 Massachusetts Department of Environmental Protection Bureau of Resource Protection -Wetlands DEP File Number: WPA Form 5 - Order of Conditions 242-1292 Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 C. General Conditions Under Massachusetts Wetlands Protection Act (only applicable to approved projects) 1. Failure to comply with all conditions stated herein, and with all related statutes and other regulatory measures, shall be deemed cause to revoke or modify this Order. 2. The Order does not grant any property rights or any exclusive privileges; it does not authorize any injury to private property or invasion of private rights. 3. This Order does not relieve the permittee or any other person of the necessity of complying with all other applicable federal, state, or local statutes, ordinances, bylaws, or regulations. 4. The work authorized hereunder shall be completed within three years from the date of this Order unless either of the following apply: a. the work is a maintenance dredging project as provided for in the Act; or b. the time for completion has been extended to a specified date more than three years, but less than five years, from the date of issuance. If this Order is intended to be valid for more than three years, the extension date and the special circumstances warranting the extended time period are set forth as a special condition in this Order. 5. This Order may be extended by the issuing authority for one or more periods of up to three years each upon application to the issuing authority at least 30 days prior to the expiration date of the Order. 6. Any fill used in connection with this project shall be clean fill. Any fill shall contain no trash, refuse, rubbish, or debris, including but not limited to lumber, bricks, plaster, wire, lath, paper, cardboard, pipe, tires, ashes, refrigerators, motor vehicles, or parts of any of the foregoing. 7. This Order is not final until all administrative appeal periods from this Order have elapsed, or if such an appeal has been taken, until all proceedings before the Department have been completed. 8. No work shall be undertaken until the Order has become final and then has been recorded in the Registry of Deeds or the Land Court for the district in which the land is located, within the chain of title of the affected property. In the case of recorded land, the Final Order shall also be noted in the Registry's Grantor Index under the name of the owner of the land upon which the proposed work is to be done. In the case of the registered land, the Final Order shall also be noted on the Land Court Certificate of Title of the owner of the land upon which the proposed work is done. The recording information shall be submitted to this Conservation Commission on the form at the end of this Order, which form must be stamped by the Registry of Deeds, prior to the commencement of work. 9. A sign shall be displayed at the site not less then two square feet or more than three square feet in size bearing the words, "Massachusetts Department of Environmental Protection" [or, WA DEP"] "File Number 242-1292 " wpaform5.doc• rev.1/10/05 Page 4 of 9 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands DEP File Number: WPA Form 5 - Order of Conditions 242-1292 Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 C. General Conditions Under Massachusetts Wetlands Protection Act 10. Where the Department of Environmental Protection is requested to issue a Superseding Order,the Conservation Commission shall be a party to all agency proceedings and hearings before DEP. 11. Upon completion of the work described herein, the applicant shall submit a Request for Certificate of Compliance(WPA Form 8A)to the Conservation Commission. 12. The work shall conform to the plans and special conditions referenced in this order. 13. Any change to the plans identified in Condition#12 above shall require the applicant to inquire of the Conservation Commission in writing whether the change is significant enough to require the filing of a new Notice of Intent. 14. The Agent or members of the Conservation Commission and the Department of Environmental Protection shall have the right to enter and inspect the area subject to this Order at reasonable hours to evaluate compliance with the conditions stated in this Order, and may require the submittal of any data deemed necessary by the Conservation Commission or Department for that evaluation. 15. This Order of Conditions shall apply to any successor in interest or successor in control of the property subject to this Order and to any contractor or other person performing work conditioned by this Order. 16. Prior to the start of work, and if the project involves work adjacent to a Bordering Vegetated Wetland, the boundary of the wetland in the vicinity of the proposed work area shall be marked by wooden stakes or flagging. Once in place, the wetland boundary markers shall be maintained until a Certificate of Compliance has been issued by the Conservation Commission. 17. All sedimentation barriers shall be maintained in good repair until all disturbed areas have been fully stabilized with vegetation or other means. At no time shall sediments be deposited in a wetland or water body. During construction, the applicant or his/her designee shall inspect the erosion controls on a daily basis and shall remove accumulated sediments as needed. The applicant shall immediately control any erosion problems that occur at the site and shall also immediately notify the Conservation Commission, which reserves the right to require additional erosion and/or damage prevention controls it may deem necessary. Sedimentation barriers shall serve as the limit of work unless another limit of work line has been approved by this Order. Special Conditions: If you need more See attached space for additional conditions, select box to attach a text document wpaform5.doc• rev.1/10/05 Page 5 of 9 L1Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands DEP File Number: 11 WPA Form 5 - Order of Conditions 242-1292 Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 D. Findings Under Municipal Wetlands Bylaw or Ordinance 1. Furthermore, the North Andover hereby finds (check one that applies): Conservation Commission 2. ❑ that the proposed work cannot be conditioned to meet the standards set forth in a municipal ordinance or bylaw specifically: a. Municipal Ordinance or Bylaw b.Citation Therefore, work on this project may not go forward unless and until a revised Notice of Intent is submitted which provides measures which are adequate to meet these standards, and a final Order of Conditions is issued. s. ® that the following additional conditions are necessary to comply with a municipal ordinance or bylaw: North Andover Wetland Protection Bylaw Chapter 178 a.Municipal Ordinance or Bylaw b.Citation The Commission orders that all work shall be performed in'accordance with the following conditions and with the Notice of Intent referenced above. To the extent that the following conditions modify or differ from the plans, specifications, or other proposals submitted with the Notice of Intent, the conditions shall control. If you need more c. The special conditions relating to municipal ordinance or bylaw are as follows: space for additional See Attached conditions, select box to attach a text document I� wpaform5.doc• rev.1/10/05 Page 6 of 9 DEP FILE #242 - 1292 Therefore, the North Andover Conservation Commission(hereafter the "NACU) hereby finds that the following conditions are necessary,in accordance with the Performance Standards set forth in the State Regulations, the local Bylaw and Regulations, to protect those interests noted above. The NACC orders that all work shall be performed in accordance with said conditions and with the Notice of Intent referenced below. To the extent that the following conditions modify or differ from the flans, specifications or other proposals submitted with the Notice of Intent, the conditions shall control GENERAL CONDITIONS 18. Failure to comply with all conditions stated herein, and with all related statutes and other regulatory measures, shall be deemed cause to revoke or modify this Order. 19. This Order does not grant any property rights or any exclusive privileges;it does not authorize any injury to private property or invasion of property rights. However, the NACC, agent of the NACC or the Department of Environmental Protection(DEP) reserves the right to enter and inspect the property at all reasonable times until a Certificate of Compliance is issued, to evaluate compliance with this Order of Conditions, the Act(310 CMR 10.00), the North Andover Wetland Bylaw and Regulations, and may require any information,measurements,photographs, observations,and/or materials, or may require the submittal of any data or information deemed necessary by the NACC for that evaluation. Further, work shall be halted on the site if the NACC, agent or DEP determines that any of the work is not in compliance with this Order of Conditions. Work shall not resume until the NACC is satisfied that the work will comply and has so notified the applicant in writing. 20. This Order does not relieve the permittee or any other person of the necessity of complying with all other applicable federal, state or local statutes, ordinances,by-laws or , regulations. 21. The work authorized hereunder shall be completed within three years from the date of this order. 22. This Order may be extended by the issuing authority for one or more periods of up to one year each upon application to the issuing authority at least thirty days (30) prior to the expiration date of the Order (Refer to Section 8.3 (p.37) of the North Andover Wetland Regulations). 23. The NACC reserves the right to amend this Order of Conditions after a legally advertised public hearing if plans or circumstances are changed or if new conditions or information so warrant. C:\Winword\OOC\35WrightAvenue.doc 1 NACC 2/3/05 1 T DEP FILE # 242 - 1292 24. Where the Department of Environmental Protection (DEP) is requested to make a determination and to issue a Superseding Order, the Conservation Commission shall be a party to all agency proceedings and hearings before the Department. 25. This Order of Conditions is issued under DEP File No. 242-1292. 26. The conditions of this decision shall apply to, and be binding upon, the applicant, owner, its employees and all successors and assigns in interest or control. These obligations shall be expressed in covenants in all deeds to succeeding owners of portions of the property. 27. The term"Applicant" as used in this Order of Conditions shall refer to the owner,any successor in interest or successor in control of the property referenced in the Notice of Intent, supporting documents and this Order of Conditions. The NACC shall be notified in writing within 30 days of all transfers of title of any portion of property that takes place prior to the issuance of a Certificate of Compliance. 28. The proposed work includes: Construction of a 20'x 24' addition to an existing single- family dwelling with associated grading within the Buffer Zone to Bordering Vegetated Wetland (BVW). 29. The work shall conform to the following (except as noted in the remainder of this document where revisions may be required): Notice of Intent filed by: Susan Hansen(Applicant) 35 Wright Avenue North Andover,MA 01845 Received date:December 22,2004 Site Plans prepared by: New England Engineering Services,Inc. Entitled, "Site Plan: 35 Wright Ave,North Andover,MA", dated December 22,2004. Signed & Stamped by Benjamin C. Osgood,P.E. 30. The following wetland resource areas are affected by the proposed work: Buffer Zone to Bordering Vegetated Wetland (BVW). These resource areas are significant to the interests of the Act and Town Bylaw as noted above and therein. The applicant has not attempted to overcome the presumption of significance of these resource areas to the identified interests. 31. The NACC agrees with the applicant's delineation of the wetland resource areas on site as shown on the plans dated December 22, 2004,referenced herein with the exception of wetland flag A-4. C:\Winword\OOC\35WrightAvenue.doc 2 NACC 2/3/05. r DEP FILE #242 - 1292 32. The NACC finds that the intensive use of the upland areas and buffer zone proposed on this site will cause further alteration of the wetland resource areas. In order to prevent any alteration of wetland resource areas a twenty five foot(25') No-Disturbance Zone and a fifty foot (50') No-Construction Zone shall be established from the edge of the adjacent wetland resource area except in those locations as depicted on the approved record plan and in those locations that have been historically maintained as lawn. No further disturbance of the 25' No-Disturbance Zone and the 50' No-Build Zone shall be allowed. The Conservation Administrator and/or other agents of the NACC do not have the authority to waive these setbacks as established under the local bylaw. No disturbance of existing.grade, soils or vegetation is permitted in the No-Disturbance zone. (See Section 3.4 &Appendix F of the local Regulations). 33. This document shall be included in all construction contracts, subcontracts, and specifications dealing with the work proposed and shall supersede any conflicting contract requirements. The applicant shall assure that all contractors, subcontractors, and other personnel performing the permitting work are fully aware of the permits terms and conditions. Thereafter, the contractor will be held jointly liable for any violation of this Order resulting from failure to comply with its conditions. 34. The owners of the project and their successors in title, in the event they proceed to alter areas subject to the Commissions jurisdiction under the order, agree that the Order does not in itself impose upon the Town any responsibility to maintain the proposed drainage system and that said Town shall not be liable for any damage in the event of failure. By acceptance of this Order, the owners agree to indemnify and hold harmless to the Town and its residents for any damage attributable to alterations undertaken on this property pursuant to the Order. Maintenance of the drainage system, if accepted by the Town as part of a public way,becomes the responsibility of the Town. 35. Issuance of these Conditions does not in any way imply or certify that the site or downstream areas will not be subject to flooding, storm damage or any other form of water damage. PRIOR TO CONSTRUCTION 36. No work shall be undertaken until all administrative appeal periods from this Order have elapsed or, if such an appeal has been filed,until'all proceedings before the Department or Court have been completed. 37. This Order shall be recorded by the applicant at the Registry of Deeds immediately after the expiration of all appeal periods. No work shall be undertaken until the Final Order has been recorded in the Y Re 'str of Deeds or the Land Court for the district in which the Registry land is located,within the chain of title of the affected property. In the case of recorded land, the Final Order shall also be noted in the Registry's Grantor Index under the name of the owner of the land upon which the proposed work is to be done. In the case of C:\Winword\OOC\35WrightAvenue.doe 3 NACC 2/3/05 DEP FILE #242 - 1292 registered land, the Final Order shall also be noted on the Land Court Certificate of Title of the owner of the land upon which the proposed work is to be done. The recording information shall be submitted to the North Andover Conservation Commission on the form at the end of this Order prior to commencement of the work. Any Order not recorded by the applicant before work commences may be recorded by the NACC at the applicant's expense. 38. A sign shall be displayed at the site not less than two square feet or more than three square feet in size bearingthe words"Massachusetts DEP,File Number 242-1292." 39. Any changes in the submitted plans caused by the applicant, another board's decision or resulting from this Order of Conditions must be submitted to the NACC for approval prior to implementation. If the NACC finds said changes to be significant, the NACC will call for another public hearing(at the expense of the applicant). Within 21 days of the close of said public hearing the NACC will issue an amended or new Order of Conditions. Any errors found in the plans or information submitted by the applicant shall be considered as changes.The proposed project may be still under review by other local or state boards or agencies. This may result in changes to the project plans or wetland impacts. If any such changes occur a revised plan and an explanation of the revisions shall be submitted to the NACC for review and approval prior to the start of construction. No work shall begin on a project until written approval has been granted by the NACC. 40. It is the responsibility of the applicant, owner,and/or successor(s) to ensure that all conditions of this Order of Conditions are complied with. The project engineer and contractors are to be provided with a copy of this Order of Conditions and referenced documents before commencement of construction. 41. Prior to any work commencing on-site,the applicant shall submit to the NACC for approval, a detailed sequence of construction,including but not limited to the installation of erosion/ sedimentation control devices and any re-vegetation to be completed before other work begins on-site. 42. Wetland flagging shall be checked prior to start of construction and shall be re-established where missing. All wetland flagging shall remain visible and enumerated per the approved plan(s) throughout the life of the project and until a Certificate of Compliance is issued so that erosion control measures can be properly placed and wetland impacts can be monitored. The proposed limit of work shall be shall be clearly marked with stakes or flags and shall be confirmed by the NACC. Such markers shall be checked and replaced as necessary and shall be maintained until all construction is complete. Workers should be informed that no use of machinery,storage of machinery or materials, stockpiling of soil, or construction activity is to occur beyond this line at any time. All flags used for the I� above purposes shall be of a color different from other fla ggin g used on the site. C:\Winword\OOC\35WrightAvenue.doc 4 NACC 2/3/05 r DEP FILE #242 - 1292 43. A row of staked hay bales backed by trenched siltation fence shall be placed between all construction areas and wetlands. The erosion control barrier will be properly installed and placed as shown on the plans approved and referenced herein and shall be inspected and approved by the NACC prior to the start of construction and shall remain intact until all disturbed areas have been permanently stabilized to prevent erosion. All erosion prevention and sedimentation protection measures found necessary during construction shall be implemented at the direction of the NACC, The NACC reserves the right to impose additional conditions on portions of this project to mitigate any impacts which could result from site erosion, or any noticeable degradation of surface water quality discharging from the site. For example, installation of erosion control measures may be required in areas not shown on the plan(s) referenced in this Order of Conditions. Should such installation be required by the NACC, they shall be installed within 48 hours of the Commission's request. 44. The applicant shall have on hand at the start of any soil disturbance, removal or stockpiling, a minimum of 10 hay bales and sufficient stakes for staking these bales (or an equivalent amount of silt fence). Said bales shall be used only for the control of emergency erosion problems and shall not be used for the normal control of erosion. 45. A check payable to the Town of North Andover shall be provided in the amount of $2,000, which shall be in all respects satisfactory to Town Counsel, Town Treasurer, and the NACC, and shall be posted with the North Andover Town Treasurer through the NACC before commencement of work. Said deposit of money shall be conditioned on the completion of all conditions hereof,shall be signed by a party or parties satisfactory to the NACC, and Town Counsel, and shall be released after completion of the project, provided that provisions, satisfactory to the NACC,have been made for performance of any conditions which are of continuing nature. The applicant may propose a monetary release schedule keyed to completion of specific portions of the project for the NACC's review and approval. This condition is issued under the authority of the local Bylaw. 46. The applicant shall designate a Professional Wetland Scientist as the project's "Erosion Control Monitor" (ECM) to oversee any emergency placement of controls and regular inspection or replacement of sedimentation control devices. The name and phone number of the erosion control monitor must be provided to the NACC in the event that this person has to be contacted,due to an emergency at the site, during any 24-hour period, including weekends. This professional must submit a letter to the Conservation Department,on company letterhead stating they have been retained as the project's Erosion Control Monitor. The designated Erosion Control Monitor is subject to approval by the NACC. This person shall also be given the authority to stop construction for erosion control purposes. The ECM will be required to inspect all such devices and oversee cleaning and the proper disposal of waste products. Cleaning shall include removal of any entrapped silt. C:\Winword\OOC\35WrightAvenue.doe 5 NACC 2/3/05 DEP FILE #242 - 1292 47. At least ONCE during each week, or otherwise arranged by the NACC, in which construction activities occurs on-site and for as long thereafter as ground remains unstable, it is the applicant's responsibility that the Environmental/Erosion Control Monitor (EMC) monitors the site and submits a written report to the NACC. The EMC shall certify that,to the best of his/her knowledge and belief based on a careful site inspection, all work is being performed in compliance with this Order of Conditions and that approved setbacks are being adhered to. The EMC must visually inspect all sedimentation/ erosion control measures and assume responsibility for their maintenance on a weekly basis and that they are functioning as intended. In addition, all wetland resource areas must be visually inspected for siltation, turbidity, and/or other water quality impacts. The reports shall also include current condition of erosion and sedimentation controls; describe any erosion or sedimentation repair and / or replacement; and describe any erosion or sedimentation problems and mitigation measures implemented. Such reports shall continue until the applicant requests a less frequent reporting schedule or an end to reports. This request must be submitted in writing and is subject to approval by the Conservation Administrator. 48. Prior to construction, the applicant shall permanently mark the edge of disturbance with five (5) signs or markers spaced evenly every 30 feet incorporating the following text: "Protected Wetland Resource Area". This will designate their sensitivity and assure no further inadvertent encroachment into the wetland. These permanent markers shall be placed along the existing chain link fence or on existing trees directly behind the fence. The applicant shall instruct all agents to explain these markers to buyers/lessees/landscapers and all persons taking over the property from the applicant. 49. The applicant and/or the legal owner of that portion of land upon which these Orders of Conditions have been placed shall provide to the NACC prior to transferring,or assigning any portion of said land to another party,subject to said Orders of Conditions,the "Compliance Certification Form Affidavit" attached via "Appendix A" signed under the pains and penalties of perjury,stating that said applicant and/or owner has read these Orders of Conditions and is in compliance with each and every condition. This document shall apply to each of the conditions referenced herein and shall be provided to the Conservation Department at least five (5) business days after to the closing of said land transaction. 50. Once these above mentioned pre-construction requirements are complete,the applicant shall contact the Conservation Office prior to site preparation or construction and shall arrange an on-site conference with an NACC representative,the contractor,the engineer,wetland scientist and the applicant to ensure that all of the Conditions of this Order are understood. This Order shall be included in all construction contracts, subcontracts, and specifications dealing with the work proposed and shall supersede any conflicting contract requirements. The applicant shall assure that all contractors, subcontractors and other personnel performing the permitted work are fully aware of the permit's terms and conditions. Thereafter,the contractor will be held jointly liable for any violation of this Order of Conditions resulting from failure to comply with its conditions. C:\Winword\OOC\35WrightAvenue.doc 6 NACC 2/3/05 r I DEP FILE #242 - 1292 The applicant or contractor shall notify the NACC in writing of the identity of the on-site construction supervisor hired to coordinate construction and to ensure compliance with this Order. A reasonable period of time shall be provided as notice of the pre- construction meeting(e.g. 72 hours). DURING CONSTRUCTION 51.Accepted engineering and construction standards and procedures shall be followed in the completion of the project. 52. Access for construction shall be prohibited to the north of the property (along and through the existing driveway) due to the close proximity of the wetland resource area in this location. Access shall be restricted to the right fagade of the dwelling only. 53. A crushed stone construction entrance shall be designated along the right fagade of the dwelling to minimize soil/material tracking onto Wright Avenue. This entrance shall be reinforced as necessary. 54. The NACC expressed concerns with the discharge point of the existing pool waters, specifically discharging directly towards the adjacent Bordering Vegetated Wetland (BVW). In order to protect the 'interests'of the MA Wetlands Protection Act,the discharge of any pool waters and any other pool associated discharges shall be relocated no less than 50-feet away from the edge of the BVW. The new discharge point shall be subject to review and approval by the Conservation Administrator. Pool waters shall be discharged greater than 50 feet away from the edge of the BVW and directed away from the wetland resource area in perpetuity to this Order. 55. De-watering activities anticipated shall be supervised and witnessed by a representative from the North Andover Conservation Commission. This person must be on-site while work specific to de-watering activities are occurring and until complete. Activities shall be monitored daily by the Conservation Staff to ensure that sediment laden water is appropriately settled prior to discharge toward the wetland resource areas. No discharge of water is allowed directly into an area subject to jurisdiction under the MA Wetlands Protection Act and / or the North Andover Wetlands Bylaw. If emergency de-watering requirements arise,the applicant shall submit a contingency plan to the Commission for approval,which provides for the pumped water to be contained in a settling tank or basin, to reduce turbidity prior to discharge into a resource area. C:\Winword\OOC\35WrightAvenue.doe 7 NACC 2/3/05 t DEP FILE #242 - 1292 56. There is existing shed located within the boundary of the Bordering Vegetated Wetland and within the 25-foot No Disturbance Zone and the 50-foot No-Build Zone.The shed has also been determined to be located off property. The applicant shall relocate the shed to an approved location outside of the 50-foot No-Build Zone subject to approval by the Conservation Administrator. The removal/dismantling of the shed must be done by hand. The use of equipment and /or machinery is strictly prohibited. In addition,the area in and around the location of the existing shed is determined to be historically filled yard waste. Therefore any yard waste,including but not limited to grass clippings, leaf piles, brush piles, and any other fill materials, shall be removed by hand,rake, shovel and /or wheel borrow, in order to allow the area to naturally re-vegetate.The use of equipment and /or machinery is strongly prohibited. Enhancement plantings shall also be proposed by the Environmental Monitor to be planted in this location. The proposed plantings shall be subject to approval by the Conservation Administrator. The aforementioned activities shall be completed during construction activities. 57. All soil/material stockpile shall be placed in the area designated as"Soil Stockpiling Area", as depicted on the approved plans referenced herein. 58. All waste generated by, or associated with,the construction activity shall be contained within the construction area, and away from any wetland resource area. There shall be no burying of spent construction materials or disposal of waste on the site by any other means. The applicant shall maintain dumpsters (or other suitable means) at the site for the storage and removal of such spent construction materials off-site. However, no trash dumpsters will be allowed within 50 feet of the wetland resource area (BVW).Therefore,trash dumpsters placed within the limits of the existing driveway is strictly prohibited. Storage of construction materials and/or equipment and soils are also strictly prohibited within 50 feet of the BVW and within the limits of the existing driveway. 59. Any fill used in connection with this project shall be clean fill,containing no trash, refuse, rubbish or debris, including but not limited to lumber,bricks, plaster,wire, lath, paper, cardboard, pipe,tires, ashes,refrigerators,motor vehicles or parts on any of the foregoing. 60. No re-grading in the buffer zone shall have a slope steeper than 2:1 (horizontal: vertical). Slopes of steeper grade shall be permanently stabilized using clean, stone riprap or biodegradable matting. 61. All exposed soil finish grade surfaces shall be immediately landscaped and stabilized, or loamed, seeded and mulched,with a layer of mulch hay. All disturbed areas must be graded, loamed and seeded prior to November 1st of each year.Outside of the growing season, exposed soil finish grade surfaces shall be stabilized with a layer of mulch hay until climate conditions allow for seeding. During construction, any area of exposed soils that will be left idle for more than 30 days shall be stabilized with a layer of mulch hay or other means approved by the NACC. C:\Winword\OOC\35WrightAvenue.doc 8 NACC 2/3/05 DEP FILE # 242 - 1292 62. Washings from concrete trucks, or surplus concrete, shall not be directed to, any drainage system, or wetland resource area. 63. During and after work on this project,there shall be no discharge or spillage of fuel, or other pollutants into any wetland resource area. If there is a spill or discharge of any pollutant during any phase of construction the NACC shall be notified by the applicant within one 1 business day. No construction vehicles are to be stored within 100 feet of O Y wetland resource areas, and no vehicle refueling, equipment lubrication, or maintenance is to be done within 100 feet of a resource area. AFTER CONSTRUCTION 64. No underground storage of fuel oils shall be allowed on any lot within one hundred (100) feet of any wetland resource area. This condition shall survive this Order of Conditions and shall run with the title of the property. This condition is issued under the authority of the Town's Wetland protection Bylaw. 65. Fertilizers utilized for landscaping and lawn care shall be slow release, low-nitrogen types (< 5%), and shall not be used within 25 feet of a resource area. Pesticides and herbicides shall not be used within 100 feet of a wetland resource area. This condition shall survive this Order of Conditions and shall run with the title of the property. This condition is issued under the authority of the Town's Wetland Protection Bylaw and shall remain in perpetuity. 66. Upon completion of construction and grading, all disturbed areas located outside resource areas shall be stabilized permanently against erosion. This shall be done either by loaming and seeding according to SCS standards. If the latter course is chosen, stabilization will be considered complete once vegetative cover has been achieved. 67. Upon approved site stabilization by Conservation staff,the erosion controls shall be removed and properly disposed of and all exposed un-vegetated areas shall be seeded. 68. Upon completion of the project the applicant shall submit the following to the Conservation Commission as part of a request for a Certificate of Compliance: a. WPA Form 8A- "Request for a Certificate of Compliance." b. A letter from the applicant requesting a Certificate of Compliance. c. The name and address of the current landowner. d. Signed statements from the individual property owners shall be submitted with the request for a Certificate of Compliance indicating that they read and understood the recorded Order of Conditions prior to purchasing their property. e. The name and address of the individual / trust or corporation to whom the compliance is to be granted. C:\Winword\OOC\35WrightAvenue.doc 9 NACC 2/3/05 DEP FILE #242 - 1292 f. The street address and assessor's map / parcel number for the project. g. The DEP file number. h. A written statement from a Registered Professional Civil Engineer (and/or Registered Professional Land Surveyor) of the Commonwealth certifying that the work has been conducted as shown on the plan(s) and documents referenced above, and as conditioned by the Commission. i. An"As-Built" plan prepared and signed and stamped by a Registered Professional Civil Engineer (and/or Registered Professional Land Surveyor) of the Commonwealth,for the public record. This plan will include: ➢ "As-Built" post-development elevations and grades of all filled or altered wetland resource areas including the encompassing buffer zone,which is regulated as a resource area under the local Wetland Protection Bylaw. ➢ Distances from structures to wetland resource areas. Structures include,but are not limited to, septic systems, additions, fences, shed, stonewalls, pools,retaining walls, subsurface utilities and decks. ➢ A line showing the limit of work and the extent of existing erosion control devices. "Work" includes AU disturbance of soils or vegetation. ➢ Location of all subsurface utilities entering the property. 69. The following special conditions shall survive the issuance of a Certificate of Compliance (COC) for this project: ➢ 25' No-Disturbance Zone and a 50' No-Construction Zone shall be established from the edge of adjacent wetland resource areas except in those locations approved under this filing. Future work within 100' of existing wetland resource areas will require a separate filing with the NACC. The Conservation Administrator and/or other agents of the NACC do not have the authority to waive these setbacks as established under the local Bylaw (Condition# 32); ➢ Discharge or spillage of pollutants (Condition# 63); ➢ Prohibition of underground fuels (Condition#64); ➢ Limitations on the use of fertilizers, herbicides, and pesticides (Conditions #65). ➢ Discharge of pool waters within 50 feet of the wetland resource area (Condition #54). C:\Winword\OOC\35WrightAvenue.doc 10 NACC 2/3/05 I + DEP FILE #242 - 1292 APPENDIX A— AFFIDAVIT I, on oath do hereby depose and state: (authorized agent of applicant and/ or owner) (PLEASE CHECK AT LEAST ONE BLOCK) 1) I am the of (position with applicant) (applicant's name) the applicant upon whom the Order of Conditions have been (DEP or NACC File#) placed upon by the North Andover Conservation Commission (NACC). and / or 2) I am the of (position with owner) (owner) the owner upon whose land Order of Conditions have been (DEP or NACC File#) placed upon by the NACC. ♦ I hereby affirm and acknowledge that I have received said Order of Conditions and have read the same and understand each and every condition,which has been set forth in said Order of Conditions. ♦ I hereby affirm and acknowledge that on this day of 20---, I inspected said property together with any and all improvements, which have been made to the same and hereby certify that each and every condition set forth in the Order of Conditions are presently in compliance. ♦ I hereby affirm and acknowledge that this document will be relied upon by the NACC,as well as any potential buyers of said property, which is subject to the Order of Conditions. Signed under the pain and penalties of perjury this day of ;20 (Authorized agent of applicant or owner) C:\Winword\OOC\35WrightAvenue.doc 11 NACC 2/3/05 Massachusetts Department of Environmental Protection Bureau of Resource Protection -Wetlands DEP File Number: WPA Form 5 - Order of Conditions 242-1292 Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 E. Issuance s This Order Is valid for three years, unless otherwise specified as a special a AI -os condition pursuant to General Conditions#4, from the date of issuance. 1.Date of s ante Please indicate the number of members who will sign this form: 6- This Order must be signed by a majority of the Conservation Commission. 2.Number of signers The Order must be mailed by certified mail (return receipt requested)or hand delivered to the applicant. A copy also must be mailed or hand delivered at the same time to the appropriate Department of Environrpental Protection Regi al Office, if not filing electronically, and the property owner, if different from app cant. ' Signatu es: a -AL 4 Notary Acknowledgement Commonwealth of Massachusetts County of Essex North In il� 0-r o�4Os On this Day °f Month — Year Before me, the undersigned Notary Public, 5 C 0 personally appeared Name of Document signer proved to me through satisfactory evidence of identification, which was/were Massachusetts License Description of evidence of identification to be the person whose name is signed on the preceding or attached document, and acknowledged to me that he/she signed it voluntarily for its stated purpose. As member of North Andover Conservation Commission City/Town 'gnature of Notary Public 10, F**-C �AL4?' Printed Name of Notary Public Place nota seal and/or an stamp above k 12/o?.Oaq notary Y My Commission/Expires(Date) This Order is issued to the applicant as follows: ❑ by hand delivery on e�/by certified mail, return receipt requested, on �3�oS Date Date T wpaform5.doc• rev.1/10/05 Page 7 of 9 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands DEP File Number: WPA Form 5 - Order of Conditions 242-1292 Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 F. Appeals The applicant,the owner, any person aggrieved by this Order, any owner of land abutting the land subject to this Order, 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 DEP Regional Office to issue a Superseding Order of Conditions. The request must be made by certified mail or hand delivery to the Department, with the appropriate filing fee and a completed Request of Departmental Action Fee Transmittal Form, as provided in 310 CMR 10.03(7)within ten business days from the date of issuance of this Order. 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 Order which is being appealed and how the Order does not contribute to the protection of the interests identified in the Massachusetts Wetlands Protection Act, (M.G.L. c. 131, §40) and is inconsistent with the wetlands regulations (310 CMR 10.00). To the extent that the Order is based on a municipal ordinance or bylaw, and not on the Massachusetts Wetlands Protection Act or regulations, the Department has no appellate jurisdiction. Section G,Recording Information is available on the following page. Page 8 of 9 wpaform5.doc• rev.1/10/05 � r LlMassachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands DEP File Number: WPA Form 5 - Order of Conditions 242-1292 Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 G. Recording Information This Order of Conditions must be recorded in the Registry of Deeds or the Land Court for the district in which the land is located, within the chain of title of the affected property. In the case of recorded land, the Final Order shall also be noted in the Registry's Grantor Index under the name of the owner of the land subject to the'Order. In the case of registered land, this Order shall also be noted on the Land Court Certificate of Title of the owner of the land subject to the Order of Conditions. The recording information on Page 7 of this form shall be submitted to the Conservation Commission listed below. North Andover Conservation Commission Detach on dotted line, have stamped by the Registry of Deeds and submit to the Conservation Commission. --------------------------------------------------------------------------------------------------------------------------- To: North Andover Conservation Commission Please be advised that the Order of Conditions for the Project at: 242-1292 Project Location DEP File Number Has been recorded at the Registry of Deeds of: County Book Page for: Property Owner and has been noted in the chain of title of the affected property in: Book Page In accordance with the Order of Conditions issued on: Date If recorded land, the instrument number identifying this transaction is: Instrument Number If registered land, the document number identifying this transaction is: Document Number Signature of Applicant wpaform5.doc• rev.1110/05 Page 9 of 9