HomeMy WebLinkAboutBuilding Permit #358-11 - 18 INGLEWOOD STREET 10/28/2010 BUILDING-PERMIT poRTy
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION _.:•_ '
Permit NO: ITmoo , a
Date Received / 41
Date Issued' �9SSACHUS����
IMPORTANT:Applicant must complete all items on this e
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TYPE OF IMPROVEMENT P •OP-OS•ED USE
esidential ) Non- Residential
New Building ne amily _
Addition Two or more family Industrial
teratio No. of units: Commercial
Repair, replacement Assessory Bldg
Demolition Other Others:
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DESCRIPTION OF WORK TO BE PREFORMED: -
Identificatipn, Pie; a Typ or Print CIearIy)
OWNER: Name: ckD � >
Phone:
Address:
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ARCHITECT/ENGINEER Phone:
Address: Reg, No.
FEE SCHEDULE:BULDING PERM/T:$12.00 PER$9000.00 OF THE TOTAL EST/MATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $_ ��
FEE:
Check No.:
eceipt No.:
NOTE: Persons contyac ' i
's i d n ors do not have access to the Q
:Tb my a�a n
u u d
S
-'.si nature f on;r
Plans Submitted Plans Waived Certified Plot:Plan I Stamped Plans
TYPE OF SEWERAGE DISPOSAL
ublic Sewer Tanning/Massage/Body Art Swimming Pols '
Well
Tobacco Sales
Food S�ar�k bit Slee ;�t
Private(septic tank;etc. Permanent Dumpster on Site
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF -U FORM
DATE REJECTED DATE APPROVED-
PLANNING &.DEVELOPMENT
COMMENTS
CONSERVATION Reviewed on Sign ture
UVIVIMIZN IS E Ce)n S, r
A , S
HEALTH V Reviewed on Signature
COMMENTS
01
I
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water& Sewer Connection/Signature&Date Driveway Permit
DPW Town Engineer: Signature:
•--'' Ld%, dt,.4� s ood Street
� �?i�Z���E_��►SR�_-ME#A�T :��e�� ,u r�p�ter.onsite �e� _ =no ` � �,. .�.::
i"Fi_s� '�;R.! -J• _ _ n3 B'"• -_ C F n4Sy .�•i_ — _�. —__ :.t.;.r�:� i Ax T _.?-
.? •_...'[.� —o-rd: -ate, - ?,r. :^ - - . :..:--- 2Y:>^:.�>::r
.Locatedirk;Si :-: r
TES? L}�arWrra9'RE a,c ee.21
+.t.
1L•-�J:M�IJt=;i�iT�S �C �� ._ _ - •1 . � �. . � _ _- __ `. .. �.'�
_
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
3
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
NOTES and DATA— (For department use)
4�
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❑ Notified for pickup - Date
Doe.Building Permit Revised 2010
Building Department
The following is'a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Inferior Rehabilitation Permits
❑ Building Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy Of N.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
❑ Floor-Plan Or Proposed Interior Work
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or..Decks
❑ Building Permit Application
❑ Certified Surveyed Plot Plan
❑- Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ "ass check Energy Compliance Report (If Applicable) _
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg_Permit j
_-New Construction (Single and Two Family)
❑ Building Permit Application
� a r•_ r�
❑ 1�el tl:l�u Proposed Pion
t Pla .
❑ Photo of H.I.C. And C.S.L. Licenses
❑ Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And j
Hydraulic Calculations (If Applicable)
❑ . Copy of Contract
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products - -
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submitted with the building application
Doc:Building Permit Revised 2008
Locatior/ 'Oel
No. n Date
�oRTM TOWN OF NORTH ANDOVER
F � e
+ s • . Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # 3
236
Building Inspector
NORT►y
Tovm of _ Andover
No. j may- . .-__
-o " dover, Mass.,T=a&
O tL- LAKE
COCMICHEWICK
0RATED PP�,�"`y
�l BOARD OF HEALTH
Food/Kitchen
PERMIT T D Septic System
BUILDING INSPECTOR
��....�.. �!!lL. ww.........
�.5... .... .................................................
THIS CERTIFIES THAT................! Foundation
has permission to ere ................:............... .... buildings on ..l..�....... ....... .."0a ................................ Rough
to be occupied as... ..... ..I .....�.u!!......... 41..� t......1.w........�i ..b. .. Chimney
..... .... ........................................................
provided that the p son accepting this permit shall in every respect conform to the terms of the application on file in Final
this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of
Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations-Voids this Permit. Rough
Final
20 — PERMIT EXPIRES IN 6 MONTHS
ELECTRICAL INSPECTOR
UNLESS CONSTRUCTIO ST TS Rough
.. ..,. . .... ... .. . .......
Service
BUILDING INSPECTOR
Final `
Occupancy Permit Required to Ocmpy Building GAS INSPECTOR
Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or Dry wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
SEE REVERSE SIDE smoke Det.
The Commonwealth of A:fassachusetts
Department o f£nduszruzl Accidents
Office of£nvestigations
..600 Washington Street
Boston, Mq 02111
gsS.gov/aEia
Workers' Compensation Insurance A.ff a
An licant Information � = Ewlders/Contractors/Electricians/Plumbers
Please Print Legibly
Name (Business/Organization/Individual):
Address: P'
City/State/Zi :
P / d Phone#:
Areyou an employer?Check the appropriate box: I V
1•F7I am a employer with 4. ❑ I am a o Type of project(required):
=eneial contractor and I
•❑ employees(full and/orpart-time).* have hired the sub-contractors 6 El construction
I am a sole proprietor or partner_ listed on the attached sheet r 7• ❑Remodeling
ship and have no employees These sum
working for me in any capacity. workers' comp.contractors have 8. ❑Demolition '
[No workers' comp. insurance 5. ❑ We are a corpora andce 9. ❑Building addition
quired) ofIts
ficershaveexercised their 10•❑Electrical repairs 3.Xletm ahomeowner doing all work ria t of„ or �0�
emption per MGL 11.❑Plumbing repairs or additions
yself [No workers'comp. c. I52
§1(4);and we have no
insurance required.] t employees. 17•❑Roof repairs
- v �t { comp.msLlran a enquired.] 13.0 Other
=a ica that check_}sox, ms:s!also �
•. fiL C;..� e,Se'.:L^r Qe.'ow°...^.CA^-=`^^�work=!com••�••co un....i:....
Iiomeowness who submitthis affidavit indicating the; a- dciag aL'wore and r
+ContraetoTM that h ); ;box mur,a a i;ed an adairioaai sheet showing the then hire outside coatxnctozsV,V' V
asbmit anew affidavit indicating such.
name of the sub-couuactors and their workers'comp_peiiny iafotmation.
I am an employer that is providing workers'com ensauon
information. P uisurance for my employees Below is the pods,and Job site
Insurance Company Name:
Policy#or Self-ins.Lic. #:
Expiration Date:
Job Site Address:
Attach a copy of the workers' compensation policy declaration as City/$tate/Zip:
Failure to secure coverage as required candor Section 2 page(showiseg the policy numberand expiration date).
fine up to$1,500.00 and/or one-yeas imprisonment,ass well as civil penaltiesintheforrm omf a STOP WORKl
Of up to $250.00 a day against the violator. Be advised that a co pees of a
PY of this statement may be forwarded to the ORDER and a n"ne
Investigations of the D for insurance coverage verification. Office of
I do hereby c , the P
`s d pe 'es of per• -th¢1 orf the in mation.provdded O7e is and correct
Simature: �
Phone 4-
Official use only. Do not write in this area, to be completedbJ'cuj,or torn offtcia(
City or Town:
PermitUcense#
Fssuing Authority(circle one):
I. Board of Health 2.Building Department 3. City/Town
_ 6. Other Clerk 4.Electrical Inspector 5.Plumbinz-Inspector
Contact Person:
Phone r:
Information an- d Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hare,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise,and including t3ae legal representatives of a deceased employer, or the
receiver or trustee of an individual,partnership, association ox-other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartni encs and who resides therein,or the occupant of the
dwelling house,of another who employs persons to do maint� lice,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or,local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to c onstruct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work un_-til acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s), address(es) and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'comp ration insurance. If an LLC or LLP does have
employees,a policy is required_ Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of irm ranee coverage. .Also be shire to sigh and date the affidavit The affidavit should
be returned to the city or town that the application for the perziattor license-is being reques:ed.,not 1fie Department of
Industrial Accidents. Should von have any euestiom regarding the law or a you zrv:,;T;teed to obtain a workers'
compensation policy,please call the Depent it the.number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly, The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant
Please be sure to fill in the permit/lic:;nse member which will be used as a reference number. In addition;an applicant
that must submit multiple permit/liceme applications in any given year,need only submit one affidavit indicating current
policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future petits or licenses. A new affidavit must be`fiIled out each .
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit
The Office of Investigations would like to than you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and.:fagnumber._....
The Commonwealth of Massachusetts
Deparbm=t of Industrial Accidents
Office cif Investegatons
600 Washington Street
Boston,ILA 0?111
Tel. 617-72.7-4940 C),-t406 or 1-8 777-MASS_FE
Revised f-26-Oi Fax -#1617-72.7-. 77'49
vrww.mass..aovf dia.
NORTH TOWN OF NORTH ANDOVER
f �
�? OFFICE OF
�� BUILDING DEPARTMENT
1600 Osgood Street Building 20, Suite 2-36
A7.yS°'o�rao aa�.t5 North Andover,Massachusetts 01845
SACHUSE
Gerald A.Brown Telephone(978)688-9545
Inspector of Buildings Fax (978)688-9542
HOMEOWNER LICENSE EXEMPTION
BUIDING PERMIT APPLICATION
Please print
DATE: C�
JOB LOCATION:
Number S e Address
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HOMEOWNER � ^-4,L�a& /_�
Name Home P ne Work Phone
PRESENT MAILING ADDRESS
City Town State Zip Code
The current exemption for"homeowners"was extended to include owner-occupied dwellings to two units or less and
to allow such homeowners to engage an individual for hire who does not possess a license,provided that the owner
acts as supervisor). State Building (Code Section 108.3.5.1)
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is,or is intended to
be,a one or two family structures. A person who constructs more that one home in a two-year period shall not be
considered a homeowner.
The undersigned"homeowner"assumes responsibility for compliances with the State Building Code and other
Applicable codes,by-laws,rules and regulations.
The undersigned"homeowner"certifies that he/she understands the Town of North Andover Building Department
minimum inspection procedures and w uirements and that he/she will comply with said procedures and
requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING OFFICIAL
Revised 7.2009
Form Homeowners Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
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CONSERVATION DEPARTMENT
Community Development Division
NEGATIVE DETERMINATION OF APPLICABILITY
SPECIAL CONDITIONS
18 Inglewood Street, North Andover
At the October 13, 2010 public hearing, the North Andover Conservation Commission (NACC)
voted to issue a Negative Determination of Applicability for the removal of an existing inground
swimming pool and backfilling of the hole with clean fill. This work will be conducted in the Buffer
Zone to Bordering Vegetated Wetland (BVW) located off property to the northeast. The closest
point of work to the BVW is more than 75 feet. The stone patio around the pool may also be
removed if necessary. Erosion control is not proposed but may be requited if patio is removed.
Applicant: Grace Mistretta
18 Inglewood Street
North Andover, MA 01845
Record Documents: Request for Determination of Applicability and aerial photos with
narrative
Date: 10/1/10
Record Plans: Aerial Photo,18 Inglewood Street, "Fill in Poop'
Dated: 10/1/10
Town of North Andover MIMAP Aerial Photo
18 Inglewood—showing BVW and Stockpile Area
Date: 10/1/10
Pre-Construction
❖ The applicant shall notify the Conservation Department at the start of work.
During Construction
•3 Excess material and construction debris shall be properly disposed of off site and stockpiled
material shall be stored on tarps and covered when not in use as described and depicted in the
approved documents referenced above.
1600 Osgood Street,Building 20,Suite 2-36,North Andover,Massachusetts 01845
Phone 978.688.9530 Fax 978.688.9542
Web:http://www.townofnordiandover.com/Pages/NAndoverMA_Conservation/index
Post Construction
:• Immediately following completion of the work, any disturbed areas shall be permanently
stabilized against erosion (loam and seed or other means approved b the Conservation
� � Y pP Y
Department if outside the growing season).
:• Upon completion of all requirements, the Conservation Department shall be contacted to
conduct a final site inspection.
1
1600 Osgood Street,Building 20,Suite 2-36,North Andover,Massachusetts 01845
Phone 978.688.9530 Fax 978.688.9542
Web:http://www.townofnorthandover.com/Pages/NAndoverMA_C6nservation/index .
Massachusetts Department of Environmental Protection
Bureau of Resource Protection -Wetlands
WPA Form 2 — Determination of Applicability
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40
A. General Information
Important:.. .
When filling out From:
forms on the North Andover
computer, use Conservation Commission
only the tab
key to move To: Applicant Property Owner(if different from applicant):
your cursor-
do not use the Grace Mistretta
return key. Name Name
18 Inglewood Street
Mailing Address Mailing Address
North Andover MA 01845
City/Town State Zip Code City/Town State Zip Code
1. Title and Date (or Revised Date if applicable) of Final Plans and Other Documents:
Aerial Photo"l 8 Inglewood Sty- Fill in Pool" 10/1/10
Title Date
Aerial Photo Town of North Andover MIMAP 10/1/10
Title Date
Title Date
2. Date Request Filed:
10/1/10
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):
Removal of pool and back filling within the Buffer Zone to Bordering Vegetated Wetland.
Project Location:
18 Inglewood Street North Andover
Street Address City/Town
Map 11 Parcel 18
Assessors Map/Plat Number Parcel/Lot Number
wpaform2.doc•Determination of Applicability•rev.10/6/04 Page 1 of 5
Massachusetts Department of Environmental Protection
ILIBureau of Resource Protection -Wetlands
WPA Form 2 - Determination of Applicability
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40
B. Determination (cont.)
The following Determination(s) is/are applicable to the proposed site and/or project relative to the Wetlands
Protection Act and regulations:
Positive Determination
Note: No work within the jurisdiction of the Wetlands Protection Act may proceed until a final Order of
Conditions(issued following submittal of a Notice of Intent or Abbreviated Notice of Intent)or Order of
Resource Area Delineation (issued following submittal of Simplified Review ANRAD) has been received
from the issuing authority(i.e., Conservation Commission or the Department of Environmental Protection).
❑ 1. The area described on the referenced plan(s)is an area subject to protection under the Act.
Removing,filling,dredging, or altering of the area requires the filing of a Notice of Intent.
❑ 2a.The boundary delineations of the following resource areas described on the referenced plan(s)are
confirmed as accurate. Therefore,the resource area boundaries confirmed in this Determination are
binding as to all decisions rendered pursuant to the Wetlands Protection Act and its regulations regarding
such boundaries for as long as this Determination is valid.
❑ 2b. The boundaries of resource areas listed below are not confirmed by this Determination,
regardless of whether such boundaries,are contained on the plans attached to this Determination or
to the Request for Determination.
❑ 3. The work described on referenced plan(s)and document(s) is within an area subject to
protection under the Act and will remove, fill, dredge, or alter that area. Therefore, said work
requires the filing of a Notice of Intent.
❑ 4. The work described on referenced plan(s) and document(s) is within the Buffer Zone and will
alter an Area subject to protection under the Act. Therefore, said work requires the filing of a
Notice of Intent or ANRAD Simplified Review(if work is limited to the Buffer Zone).
❑ 5. The area and/or work described on referenced plan(s) and document(s) is subject to review
and approval by:
Name of Municipality
Pursuant to the following municipal wetland ordinance or bylaw:
Name Ordinance or Bylaw Citation
wpaform2.doc•Determination of Applicability•rev.10/6/04 Page 2 of 5
Massachusetts Department of Environmental Protection
Bureau of Resource Protection -Wetlands
WPA Form 2 — Determination of Applicability
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 _
B. Determination (cont.)
❑ 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 pian(s)
and document(s), which includes all or part of the work described in the Request, the applicant
must consider the following alternatives. (Refer to the wetland regulations at 10.58(4)c. for more
information about the scope of alternatives requirements):
❑ Alternatives limited to the lot on which the project is located.
❑ Alternatives limited to the lot on which the project is located, the subdivided lots, and any
adjacent lots formerly or presently owned by the same owner.
❑ Alternatives limited to the original parcel on which the project is located, the subdivided
parcels, any adjacent parcels, and any other land which can reasonably be obtained within
the municipality.
❑ Alternatives extend to any sites which can reasonably be obtained within the appropriate
region of the state.
Negative Determination
Note: No further action under the Wetlands Protection Act is required by the applicant. However, if the
Department is requested to issue a Superseding Determination of Applicability, work may not proceed
on this project unless the Department fails to act on such request within 35 days of the date the
request is post-marked for certified mail or hand delivered to the Department. Work may then proceed
at the owner's risk only upon notice to the Department and to the Conservation Commission.
Requirements for requests for Superseding Determinations are listed at the end of this document.
❑ 1. The area described in the Request is not an area subject to protection under the Act or the
Buffer Zone.
❑ 2. The work described in the Request is within an area subject to protection under the Act, but will
not remove, fill, dredge, or alter that area. Therefore, said work does not require the filing of a
Notice of Intent.
® 3. The work described in the Request is within the Buffer Zone, as defined in the regulations, but
will not alter an Area subject to protection under the Act. Therefore, said work does not require
the filing of a Notice of Intent, subject to the following conditions (if any).
See attached conditions
❑ 4. The work described in the Request is not within an Area subject to protection under the Act
(including the Buffer Zone). Therefore, said work does not require the filing of a Notice of Intent,
unless and until said work alters an Area subject to protection under the Act.
wpaform2.doc•Determination of Applicability•rev.10/6/04 Page 3 of 5
Massachusetts Department of Environmental Protection
ILIBureau of Resource Protection -Wetlands
WPA Form 2 — Determination of Applicability
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40
B. Determination (cont.)
❑ 5. The area described in the Request is subject to protection under the Act. Since the work
described therein meets the requirements for the following exemption, as specified in the Act and
the regulations, no Notice of Intent is required:
Exempt Activity(site applicable statuatory/regulatory provisions)
❑ 6. The area and/or work described in the Request is not subject to review and approval by:
Name of Municipality
Pursuant to a municipal wetlands ordinance or bylaw.
North Andover Wetlands Protection Bylaw Chapter 178
Name Ordinance or Bylaw Citation
C. Authorization
This Determination is issued to the applicant and delivered as follows:
❑ by hand delivery on by certified mail, return receipt requested on
Date 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 http://www.mass.gov/dep/about/region.findyour.htm) and the
property owner(if different from the applicant).
Signat '///V
res:
kJ
Date
wpaform2.doc•Determination of Applicability•rev.10/6/04 Page 4 of 5
Massachusetts Department of Environmental Protection
ILIBureau of Resource Protection -Wetlands
WPA Form 2 — Determination of Applicability
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40
D. Appeals
The applicant, owner, any person aggrieved by this Determination, any owner of land abutting the land
upon which the proposed work is to be done, or any ten residents of the city or town in which such land is
located, are hereby notified of their right to request the appropriate Department of Environmental
Protection Regional Office(see http://www.mass.gov/dep/about/region.findvour.htm)to issue a
Superseding Determination of Applicability. The request must be made by certified mail or hand delivery
to the Department, with the appropriate filing fee and Fee Transmittal Form (see Request for
Departmental Action Fee Transmittal Form)as provided in 310 CMR 10.03(7)within ten business days
from the date of issuance of this Determination. A copy of the request shall at the same time be sent by
certified mail or hand delivery to the Conservation Commission and to the applicant if he/she is not the
appellant. The request shall state clearly and concisely the objections to the Determination which is being
appealed. To the extent that the Determination is based on a municipal ordinance or bylaw and not on the
Massachusetts Wetlands Protection Act or regulations, the Department of Environmental Protection has
no appellate jurisdiction.
wpaform2.doc•Determination of Applicability•rev.10/6/04 Page 5 of 5
Massachusetts Department of Environmental Protection
ILIBureau of Resource Protection -Wetlands
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
Phone Number Fax Number(if applicable)
Project Location
rim
Mailing Address
Cityrrown State 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)):
Name
Mailing Address
City/Town State Zip Code
Phone Number Fax Number(if applicable)
3. DEP File Number:
B. Instructions
T. 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
wpaform2.doc-Request for Departmental Action Fee Transmittal Form-rev.10/6/04 Page 1 of 2
Massachusetts Department of Environmental Protection
ILIBureau 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 Superseding
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.
wpaform2.doc•Request for Departmental Action Fee Transmittal Form•rev.10/6/04 Page 2 of 2