HomeMy WebLinkAboutMiscellaneous - 171 BRENTWOOD CIRCLE 4/30/2018 (3) FM
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Massachusetts Department of Environmental Protection
Bureau of Resource Protection -Wetlands DEP File Number:
WPA Form 86 — Certificate of Compliance 242-1569
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 Rose Sandoval
computer,use
only the tab key Name
to move your 171 Brentwood Circle
cursor-do not Mailing Address
use the return MA 01845
key. North Andover
00---h City/Town VinzA State Zip—Code
2. This Certificate of Compliance is issued for work regulated by a final Order of
Conditions issued to:
Rose Sandoval
Name 242-1569
November 15, 2012 — DEP File Number
Dated
3. The project site is located at:
171 Brentwood CircleNorth Andover
Street Address City/Town
64 Parcel 42
Map
Assessors Map/Plat Number ParceULot Number
the final Order of Condition was recorded at the Registry of Deeds for:
Rose Sandoval
Property Owner(if different)
Essex Northern 13254 313
County Book Page
Certificate
4. A site inspection was made in the presence of the applicant, or the applicant's agent,
on:
1/13/15
Date
WPA Form 8B,Certificate of Compliance•Page 1 of 3
wpafrm8b.doc•rev.5129114
LlMassachusetts Department of Environmental 'Protection
Bureau of Resource Protection -Wetlands DEP File Number:
WPA Form 8B — Certificate of Compliance 242-1569
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Provided by DEP
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: It is 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:
❑ 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Conditions has lapsed and is therefore no longer valid.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:
72
C. Authorization
Issued by:
North Andover I is
Conservation Commission Dae of l4suance
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
http://www.mass.gov/eea/agencies/massdep/about/contacts/find-the-massdep-
regional-office-for-your-city-or-town.html).
S' natures:
wpafrm8b.doc•rev.5129/14 WPA Form 88,Certificate of Compliance•Page 2 of 3
LlMassachusetts Department of Environmental Protection
Bureau of Resource Protection -Wetlands DEP File Number:
WPA Form 8B — Certificate of Compliance 242-1569
I Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 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:
171 Brentwood Circle 242-1569
Project Location DEP File Number
Has been recorded at the Registry of Deeds of:
Essex Northern
County
for:
Rose Sandoval
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
wpafrm8b.doc•rev.5129114 WPA Form 8B,Certificate of Compliance•Page 3 of 3
Massachusetts Department of Environmental Protection Provided by MassDEP:
Bureau of Resource Protection-Wetlands MassDEP File#:242-1569
l WPA Form 5-Order of Conditions eDEP Transaction#:515360
Massachusetts Wetlands Protection Act M.G.L.c. 131,§40 City/Town:NORTH ANDOVER
A. General Information
1.Conservation Commission NORTH ANDOVER
2.Issuance a. r OOC b.r Amended OOC
3.Applicant Details
a.First Name ROSE b.Last Name SANDOVAL
c.Organization
d.Mailing Address 171 BRENTWOOD CIRCLE
e.City/Town NORTH ANDOVER f.State MA g.Zip Code 01845
4.Property Owner
a.First Name ROSE b.Last Name SANDOVAL
c.Organization
d.Mailing Address 171 BRENTWOOD CIRCLE
e.City/Town NORTH ANDOVER f.State MA g.Zip Code 01845
5.Project Location
a.Street Address 171 BRENTWOOD CIRCLE
b.City/Town NORTH ANDOVER c.Zip Code 01845
d.Assessors Map/Plat#64 e.Parcel/Lot# 42
f.Latitude 42.69044N g.Longitude 71.0833W
6.Property recorded at the Registry of Deed for:
a.County b.Certificate c.Book d.Page
NORTHERN ESSEX 12606 178
7.Dates
a.Date NOI Filed:9/17/2012 b.Date Public Hearing Closed: 11/14/2012 c.Date Of Issuance: 11/15/2012
8.Final Approved Plans and Other Documents
a.Plan Title: b.Plan Prepared by: c.Plan Signed/Stamped by: d.Revised Final Date: e.Scale:
PROPOSED JM ASSOCIATES JOHN F.MCQUILKIN JR. 10-22-12 1"=40'
SWIMMING POOL P.E.
B. Findings
1.Findings pursuant to the Massachusetts Wetlands Protection Act
Page 1 of 10*ELECTRONIC COPY
Massachusetts Department of Environmental Protection Provided by MassDEP:
Bureau of Resource Protection-Wetlands MassDEP File 4:242-1569
WPA Form 5 -Order of Conditions eDEP Transaction#:515360
Massachusetts Wetlands Protection Act M.G.L.c. 131,§40 Cityrfown:NORTHANDOVER
Following the review of the 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:
F a. r Public Water Supply b. f Land Containing Shellfish c.r Prevention of Pollution M
d. r Private Water Supply e. r Fisheries f. r Protection of Wildlife Habitat
g. r Ground Water Supply h. r Storm Damage Prevention i. r. Flood Control
2.Commission hereby finds the project,as proposed,is:
Approved subject to:
a.r 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:
b.r 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 interests of the Act,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.
c.r 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 interests of the
Act,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).
3.r Buffer Zone Impacts:Shortest distance between limit of project disturbance and the wetland resource 50
area specified in 310CMR10.02(1)(a). a.linear feet
Inland Resource Area Impacts:(For Approvals Only):
Resource Area Proposed Permitted Proposed Permitted
Alteration Alteration Replacement Replacement
4. r Bank
a.linear feet b.linear feet c.linear feet d.linear feet
5.r Bordering Vegetated Wetland
a.square feet b.square feet c.square feet d.square feet
6. r Land under Waterbodies and Waterways
a.square feet b.square feet c.square feet d.square feet
e.c/y dredged f.c/y dredged
7.r Bordering Land Subject to Flooding
a.square feet b.square feet c.square feet d.square feet
Page 2 of 10*ELECTRONIC COPY
Massachusetts Department of Environmental Protection Provided by MassDEP:
Bureau of Resource Protection-Wetlands MassDEP File 4:242-1569
WPA Form 5-Order of Conditions eDEP Transaction 4:515360
l Massachusetts Wetlands Protection Act M.G.L.c. 131,§40 Citylfown:NORTH ANDOVER
1
Cubic Feet Flood Storage
e.cubic feet f.cubic feet g.cubic feet h.cubic feet
8.F-Isolated Land Subject to Flooding
a.square feet b.square feet
Cubic Feet Flood Storage
c.cubic feet d.cubic feet e.cubic feet f.cubic feet
9.C Riverfront Area
a.total sq.feet b.total sq.feet
Sq ft within 100 ft
c.square feet d.square feet e.square feet f.square feet
Sq ft between 100-200 ft
g.square feet h.square feet i.square feet j.square feet
Coastal Resource Area Impacts:
Resource Area Proposed Permitted Proposed Permitted
Alteration Alteration Replacement Replacement
10.r Designated Port Areas Indicate size under Land Under the Ocean,below
11.1-Land Under the Ocean
a.square feet b.square feet
c.c/y dredged d.c/y dredged
12.r Barrier Beaches Indicate size under Coastal Beaches and/or Coastal Dunes below
13.r Coastal Beaches
a.square feet b.square feet c.c/y nourishment d.c/y nourishment
14.r Coastal Dunes
a.square feet b.square feet c.c/y nourishment d c1y nourishment
15.r Coastal Banks
a.linear feet b.linear feet
16.r Rocky Intertidal Shores
a.square feet b.square feet
17.r Salt Marshes
a square feet b.square feet c.square feet d.square feet
18.r Land Under Salt Ponds
a.square feet b.square feet
c.c/y dredged d.c/y dredged
19.r Land Containing Shellfish
T square feet b.square feet c.square feet d.square feet
Page 3 of 10*ELECTRONIC COPY
Massachusetts Department of Environmental Protection Provided by MassDEP:
L11,1
Bureau of Resource Protection-Wetlands MassDEP File#:242-1569
WPA Form 5-Order of Conditions eDEP Transaction#:515360
Massachusetts Wetlands Protection Act M.G.L.c. 131,§40 City/fown:NORTH ANDOVER
Indicate size under Coastal Banks,inland Bank,Land Under the
20.r Fish Runs Ocean,and/or inland Land Under Waterbodies and Waterways,
above
c.c/y dredged d.c/y dredged
21.r Land Subject to Coastal Storm Flowage
a.square feet b.square feet
22.
r Restoration/Enhancement(For Approvals Only)
If the project is for the purpose of restoring or enhancing a wetland resource area in addition to the square footage that has been
entered in Section B.5.c&d or B.17.c&d above,please entered the additional amount here.
a.square feet of BV W b.square feet of Salt Marsh
23.
F Streams Crossing(s)
If the project involves Stream Crossings,please enter the number of new stream crossings/number of replacement stream crossings.
a.number of new stream crossings b.number of replacement stream crossings
C. General Conditions Under Massachusetts Wetlands Protection Act
The following conditions are only applicable to Approved projects
I. 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. If this Order constitutes an Amended Order of Conditions,this Amended Order of Conditions does not exceed the issuance
date of the original Final Order of Conditions.
7. 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.
8. 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.
9. 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,
Page 4 of 10*ELECTRONIC COPY
Massachusetts Department of Environmental Protection Provided by MassDEP:
Bureau of Resource Protection-Wetlands MassDEP File 4:242-1569
! WPA Form 5-Order of Conditions eDEP Transaction#:515360
Massachusetts Wetlands Protection Act M.G.L.c. 131,§40 City/fown:NORTHANDOVER
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 the 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..
10. 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'MassDEP"l
File Number:"242-1569"
11. 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 Mass DEP.
12. Upon completion of the work described herein,the applicant shall submit a Request for Certificate of Compliance(WPA Form
8A)to the Conservation Commission.
13. The work shall conform to the plans and special conditions referenced in this order.
14. Any change to the plans identified in Condition#13 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.
15. 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.
16. 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.
17. 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.
18. 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.
NOTICE OF STORMWATER CONTROL AND MAINTENANCE REQUIREMENTS
19. The work associated with this Order(the"Project")is(1) r is not(2)F subject to the Massachusetts Stormwater Standards.
If the work is subject to Stormwater Standards,then the project is subject to the following conditions;
a) All work,including site preparation,land disturbance,construction and redevelopment,shall be implemented in accordance
with the construction period pollution prevention and erosion and sedimentation control plan and,if applicable,the
Stormwater Pollution Prevention Plan required by the National Pollutant Discharge Elimination System Construction General
Permit as required by Stormwater Standard 8.Construction period erosion,sedimentation and pollution control measures and
best management practices(BMPs)shall remain in place until the site is fully stabilized.
b) No stormwater runoff may be discharged to the post-construction stormwater BMPs unless and until a Registered
Professional Engineer provides a Certification that:i.all construction period BMPs have been removed or will be removed by
a date certain specified in the Certification.For any construction period BMPs intended to be converted to post construction
operation for stormwater attenuation,recharge,and/or treatment,the conversion is allowed by the MassDEP Stormwater
Handbook BMP specifications and that the BMP has been properly cleaned or prepared for post construction operation,
including removal of all construction period sediment trapped in inlet and outlet control structures;ii..as-built final construction
BMP plans are included,signed and stamped by a Registered Professional Engineer,certifying the site is fully stabilized;iii.
any illicit discharges to the stormwater management system have been removed,as per the requirements of Stormwater
Page 5 of 10*ELECTRONIC COPY
L1Massachusetts Department of Environmental Protection Provided by MassDEP:
Bureau of Resource Protection-Wetlands MassDEP File#:242-1569
1 WPA Form 5-Order of Conditions eDEP Transaction#:515360
Massachusetts Wetlands Protection Act M.G.L.c. 131,§40 City/Town:NORTH ANDOVER
Standard 10;iv,all post-construction stormwater BMPs are installed in accordance with the plans(including all planting
plans)approved by the issuing authority,and have been inspected to ensure that they are not damaged and that they arc in
proper working condition;T.any vegetation associated with post-construction BMPs is suitably established to withstand
erosion.
c) The landowner is responsible for BMP maintenance until the issuing authority is noted that another party has legally assumed
responsibility for BMP maintenance.Prior to requesting a Certificate of Compliance,or Partial Certificate of Compliance,the
responsible party(defined in General Condition 19(e))shall execute and submit to the issuing authority an Operation and
Maintenance Compliance Statement("O&M Statement")for the Stormwater BMPs identifying the party responsible far
implementing the stormwater BMP Operation and Maintenance Plan("O&M Plan")and certifying the following:i.)the O&M
Plan is complete and will be implemented upon receipt of the Certificate of Compliance,and ii.)the future responsible parties
shall be notified in writing of their ongoing legal responsibility to operate and maintain the stormwater management BMPs and
implement the Stormwater Pollution Prevention Plan.
d) Post-construction pollution prevention and source control shall be implemented in accordance with the long-term pollution
prevention plan section of the approved Stormwater Report and,if applicable,the Stormwater Pollution Prevention Plan
required by the National Pollutant Discharge Elimination System Multi-Sector General Permit.
e) Unless and until another party accepts responsibility,the landowner,or owner of any drainage easement,assumes
responsibility for maintaining each BMP.To overcome this presumption,the landowner of the property must submit to the
issuing authority a legally binding agreement of record,acceptable to the issuing authority,evidencing that another entity has
accepted responsibility for maintaining the BMP,and that the proposed responsible party shall be treated as a permittee for
purposes of implementing the requirements of Conditions 19(o through 19(k)with respect to that BMP.Any failure of the
proposed responsible party to implement the requirements of Conditions 19(t)through 19(k)with respect to that BMP shall
be a violation of the Order of Conditions or Certificate of Compliance.hi the case of stormwater BMPs that are serving more
than one lot,the legally binding agreement shall also identify the lots that will be serviced by the stormwater BMPs.A plan and
easement deed that grants the responsible party access to perform the required operation and maintenance must be submitted
along with the legally binding agreement.
fl The responsible party shall operate and maintain all stormwater BMPs in accordance with the design plans,the O&M Plan,
and the requirements of the Massachusetts Stormwater Handbook.
g) The responsible party shall:
1.Maintain an operation and maintenance log for the last three(3)consecutive calendar years of inspections,repairs,
maintenance and/or replacement of the stormwater management system or any part thereof and disposal(for disposal the
log shall indicate the type of material and the disposal location);
2.Make the maintenance log available to MassDEP and the Conservation Commission("Commission")upon request;and
3.Allow members and agents of the MassDEP and the Commission to enter and inspect the site to evaluate and ensure
that the responsible party is in compliance with the requirements for each BMP established in the O&M Plan approved by
the issuing authority.
h) All sediment or other contaminants removed from stormwater BMPs shall be disposed of in accordance with all applicable
federal,state,and local laws and regulations.
i) Illicit discharges to the stormwater management system as defined in 310 CMR 10.04 are prohibited.
j) The stormwater management system approved in the Order of Conditions shall not be changed without the prior written
approval of the issuing authority.
k) Areas designated as qualifying pervious areas for the purpose of the Low Impact Site Design Credit(as defined in the
MassDEP Stormwater Handbook,Volume 3,Chapter 1,Low Impact Development Site Design Credits)shall not be altered
without the prior written approval of the issuing authority.
1) Access for maintenance,repair,and/or replacement of BMPs shall not be withheld.Any fencing constructed around
stormwater BMPs shall include access gates and shall be at least six inches above grade to allow for wildlife passage.
Special Conditions:
SEE ATTACHED.
Page 6 of 10*ELECTRONIC COPY
LI0Massachusetts Department of Environmental Protection Provided by MassDEP:
Bureau of Resource Protection-Wetlands MassDEP File 4:242-1569
'"TA Form 5-Order of Conditions eDEP Transaction#:515360
Massachusetts Wetlands Protection Act M.G.L.c. 131,§40 City/Ibwn:NORTH ANDOVER
Page 7 of 10*ELECTRONIC COPY
Massachusetts Department of Environmental Protection Provided by MassDEP:
Bureau of Resource Protection-Wetlands MassDEP File#:242-1569
WPA Form 5-Order of Conditions eDEP Transaction#:515360
Massachusetts Wetlands Protection Act M.G.L.c. 131, §40 Cityffown:NORTHANDOVER
(1R
A Findings Under Municipal Wetlands Bylaw or Ordinance
I. Is a municipal wetlands bylaw or ordinance applicable?r Yes r No
2• The Conservation Commission hereby(check one that applies);
a. r DENIES the proposed work which cannot be conditioned to
meet the standards set forth in a municipal ordinance or bylaw
specifically:
1.Municipal Ordinance or Bylaw 2.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 or Conditions is issued.Which are necessary to
comply with a municipal ordinance or bylaw:
b.
F APPROVES the proposed work,subject to the following
additional conditions.
NORTH ANDOVER
1.Municipal Ordinance or Bylaw WETLANDSPROTECTION 2.Citation CHAPTER 178
BYLAW
3. 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.
The special conditions relating to municipal ordinance or bylaw are as follows:
SEE ATTACHED.
Page 8 of 10*ELECTRONIC COPY
Massachusetts Department of Environmental Protection Provided by MassDEP:
Bureau of Resource Protection-Wetlands MassDEP File#:242-1569
r' WPA Form 5-Order of Conditions eDEP Transaction#:515360
Massachusetts Wetlands Protection Act M.G.L.c. 131,§40 City/rown:NORTH ANDOVER
E. Signatures
This Order is valid for three years from the date of issuance,unless otherwise specified 11 -15 - 11
pursuant to General Condition#4.If this is an Amended Order of Conditions,the Amended 1.Date of Ori inal Order
Order expires on the same date as the original Order of Conditions.
Please indicate the number of members who will sign this form.This Order must be signed by 2 Number of Signers
a majority of the Conservation Commission.
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 Environmental Protection Regional Office,if not filing
electronically,and the property owner,if different from applicant.
Signatures:
F by hand delivery on9"'tiffied , urn receipt requested,on
Date Date
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 MassDEP
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 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 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.
Any appellants seeking to appeal the Departments Superseding Order associated with this appeal will be required to demonstrate prior
participation in the review of this project.Previous participation in the permit proceeding means the submission of written information to
the Conservation Commission prior to the close of the public hearing,requesting a Superseding Order,or providing written information
to the Department prior to issuance of a Superseding Order.
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(3 10 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.
Page 9 of 10*ELECTRONIC COPY
Massachusetts Department of Environmental Protection Provided by MassDEP:
Bureau of Resource Protection-Wetlands MassDEP File#:242-1569
WPA Form 5-Order of Conditions eDEP Transaction#:515360
� Massachusetts Wetlands Protection Act M.G.L.c. 131,§40
Citylrown:NORTH ANDOVER
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
this page 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:
171 BRENTWOOD CIRCLE 242-1569
Project Location MassDEP File Number
Has been recorded at the Registry of Deeds of:
County Book Page
for.
Property Owner ROSE SANDOVAL
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 Rev.4/1/2010
Page 10 of 10*ELECTRONIC COPY
DEP FILE#242- 1569
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 plans,specifications or other proposals submitted with
the Notice of Intent,the conditions shall control.
GENERAL CONDITIONS
20. The proposed work includes: The construction of an in-ground pool with cartridge
style(non-backwashing)filter,concrete deck/patio,chain link fence,utilities with
appurtenant site work and grading, portions of which are within 100 feet of a Bordering
Vegetated Wetland (BVW)and ephemeral pool/ephemeral pool habitat. After the fact
approval of an existing patio and retaining wall (constructed without a filing by a prior
owner) are included in this proposal.
21.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: Steven Eriksen
Norse Environmental
92 Middlesex Road,Unit 4
Tyngsboro,MA 01879
Property Owner: Rose Sandoval
171 Brentwood Circle
North Andover,MA 01845
Site Plans prepared by: JM Associates
325 Main Street
North Reading, MA 01864
Title: Proposed Swimming Pool,171 Brentwood Circle,
North Andover,MA 01845
Dated: September 25,2012 Last Revised: 10/22/12
Signed and Stamped by:John F. McQuilkin,Jr.,P.E.
Wetland Delineation by: Norse Environmental
March 2012
Other Record Documents: Swimming Pool Maintenance Requirements
Prepared by:JM Associates
Date: October 19,2012
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DEP FILE#242-1569
22.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.
23.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.
24.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.
25.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.
26. 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.
27. The work authorized hereunder shall be completed within three years from the date of
this order.
28. This Order may be extended by the issuing authority for one but not more than two
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) of the North
Andover Wetland Regulations).
29. 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.
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30.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.
31. Any future project which proposes a wetland crossing in order to access certain
portions of the property will not be qualified as a limited project roadway under 310
CMR 10.53(e).
32.The following wetland resource areas are affected by the proposed work:Buffer Zone to
Bordering Vegetated Wetland and Ephemeral Pool and Ephemeral Pool Habitat. 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.
33. The NACC agrees with the applicant's delineation of the wetland resource areas and
the associated buffer zone on the site as shown on the plans dated and referenced
herein.
34. 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 fifty foot(50'
No-Disturbance Zone and a
seventy-five foot(75') No-Construction Zone shall be established from the edge of the
adjacent wetland resource area except for existing structures shown on the herein
referenced plan. 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).
35.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.
36. 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
37. 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.
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38.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 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 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.
39. A sign shall be displayed at the site not less than two square feet or more than three
square feet in size bearing the words"Massachusetts DEP,File Number 242-1569."
40. 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. No work shall begin on a project until written approval
has been granted by the NACC.
41. 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.
42. Prior to any work commencing on-site,the applicant shall submit to the NACC for
approval,a detailed sequence of construction,including installation of
sedimentation/erosion control devices,clearing,excavation,construction and re-
vegetation/stabilization.
43. 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 erosion controls or temporary fencing and shall be confirmed by the
NACC. Such barriers shall be checked and replaced as necessary and shall be
maintained until all construction is complete. Workers should be informed that no use
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of machinery,storage of machinery or materials,stockpiling of soil, or construction
activity is to occur beyond this line at any time.
44. Staked and trenched silt 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 or its agent 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 or its agent. 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.
45. The applicant shall have on hand at the start of any soil disturbance,removal or
stockpiling,a minimum of 25' of additional silt fence and stakes for staking. Extra
erosion controls shall be used only for the control of emergency erosion problems and
shall not be used for the normal control of erosion.
46. A check payable to the Town of North Andover shall be provided in the amount of
$1,500 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.
47. The applicant shall designate a Wetland Scientist(or other environmental professional
as approved by the NACC or its agent)as an"Erosion Control Monitor" 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. Proof of the retained monitor must be submitted to the Conservation
Department on letterhead by the retained consulting firm. This person shall be given
the authority to stop construction for erosion control purposes and the Environmental
Professional will immediately notify the Conservation agent of any matter that requires
attention by the Commission or the agent. The erosion control monitor will be required
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to inspect all such devices and oversee cleaning and the proper disposal of waste
products. Cleaning shall include removal of any entrapped silt.
48. At least once during each week in which construction activities occurs on-site and for as
long thereafter as ground remains unstabilized,the applicant shall submit a written
.report with photographs from the"Erosion Control Monitor' to the NACC certifying
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 erosion control monitor 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 Erosion Control Monitor shall be on site during
and/or following a major storm event of 1" inch of rain or greater(24 hour event)to
ensure that soils remain stable, and erosion controls are adequate and secure
49.Prior to construction,the applicant shall permanently mark the edge of the"50' No-
Disturbance Zone"with a minimum of ten(10) signs or markers and spaced evenly
every 30 feet incorporating the following text: "Protected Wetland Resource Area" and
the associated rules(3 round for every 1 square). This will designate their sensitivity
and assure no further inadvertent encroachment into the wetland. These permanent
markers are subject to review and approval by the NACC. The applicant shall instruct
all agents to explain these markers to buyers/lessees/landscapers and all persons
taking over the property from the applicant. These markers shall remain posted and be
replaced as necessary in perpetuity. Markers are available from the Conservation
Department($2 round/$3 square).
50.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 prior to
the closing of said land transaction.
51.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,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
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i
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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. 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).
STORMWATER MANAGEMENT CONDITIONS
52. There shall be no changes in post development conditions that alter the post
development watershed boundaries as currently depicted in the Notice of Intent and
approved by this Order of Conditions,unless specifically approved in writing by the
Commission.
53.Water quality in down gradient BVW' s shall not differ significantly following
completion of the project from the pre-development conditions. There shall be no
sedimentation into wetlands or water bodies from discharge pipes or surface runoff
leaving the site.
DURING CONSTRUCTION
54. Upon beginning work,the applicant shall submit written progress reports weekly (as
part of the erosion control monitoring report Condition#48 above) detailing what work
has been done in or near resource areas,and what work is anticipated to be done over
the next period.This will update the construction sequence.
55. De-watering activities are not anticipated as part of the proposed project. 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 basin,to reduce turbidity prior to discharge into a resource area.
56. 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.
57. 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.
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58. No re-grading in the buffer zone shall have a slope steeper than 2:1 (horizontal:
vertical). Slopes of steeper grade shall be rip-rapped to provide permanent
stabilization.
59.There shall be no stockpiling of soil or other materials within seventy-five(75)feet of
any resource area. All stockpiled materials shall be located in the location designated
on the approved plans.
60. Construction access will be over the existing driveway.The roadway and driveway
shall be kept free of accumulated sediment deposited by construction vehicles accessing
the site.
61.Washings from concrete trucks,or surplus concrete,shall not be directed to,any
drainage system,or wetland resource area. If truck washing is required a location for
such activity shall be approved by the Conservation Department.
62.All waste generated by,or associated with, the construction activity shall be contained
within the limit of work,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' of areas subject to protection under the Act
or local ByLaw.
63. Accepted engineering and construction standards and procedures shall be followed in
the completion of the project.
64. 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
wetland resource areas, and no vehicle refueling,equipment lubrication,or
maintenance is to be done within 100 feet of a resource area.
AFTER CONSTRUCTION
65. 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.
66.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
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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.
67. No backwashing is associated with the installed cartridge filtration. Draining of pool
water is not permitted directly into an area subject to jurisdiction of the Wetlands
Protection Act and/or the North Andover Wetland Bylaw. Pool maintenance shall be
done in accordance with the Swimming Pool Maintenance Requirements referenced in
the Record Documents herein. This condition shall survive the issuance of a Certificate
of Compliance.
68.There shall be no dumping of leaves,grass clippings,brush, or other debris into a
wetland resource areas or the 50-foot No-Disturb Zone. This condition shall remain in
perpetuity.
69. Upon completion of construction and grading, all disturbed areas located outside
resource areas shall be stabilized permanently against erosion. This shall be done by
loaming and seeding according to NRCS standards. Stabilization will be considered
complete once full vegetative cover has been achieved.
70. Upon approved site stabilization by Conservation staff,the erosion controls shall be
removed and properly disposed of and all exposed unvegetated areas shall be seeded.
71. 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.
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:
')A')_l rAQ 1'71 Rrentwnnd C'irnla OOC. 9 NACC 11/15/2012
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➢ "As-Built"post-development elevations of all drainage&stormwater
management structures constructed within 100 feet of any wetland resource
area. NOTE: If portions of the stormwater systems exist partially within the
Buffer Zone than the entire structure must be depicted to accurately verify
compliance.
➢ "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,sheds,stone walls,pools,
retaining walls,subsurface utilities and decks.
➢ A line showing the limit of work and the extent of existing erosion control
devices. "Work"includes 2Ey disturbance of soils or vegetation.
➢ Location of all subsurface utilities entering the property.
72. The following special conditions shall survive the issuance of a Certificate of
Compliance(COC)for this project:
➢ 50' No-Disturbance Zone and a 75' No-Construction Zone shall be
established from the edge of adjacent wetland resource areas except in those
locations approved under DEP#242-1569. 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);
➢ Resource Area Markers(Condition#49);
➢ Discharge or spillage of pollutants (Condition#64);
➢ Prohibition of underground fuels (Condition#65);
➢ Limitations on the use of fertilizers,herbicides and pesticides (Condition
#66).
➢ Cartridge filtration required/no backwashing or pumping to resource areas
(Condition 467)
➢ Prohibition of dumping of leaves,grass clippings,brush,or other debris
(Condition#68);
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APPENDIX A-AFFIDAVIT
I, on oath do hereby depose and state:
(authorized agent applicant and/or current owner)
(PLEASE CHECK AT LEAST ONE BLOCK)
1. 1 am the. of.
(position with applicant) (applicant name or company name)
the applicant upon whom Order of Conditions
have been placed upon by (DEP or NACC number)
the North Andover Conservation Commission.
&/or
2. 1 am the of
(position with owner) (owner name)
the owner upon whose land Order of Conditions
have been placed up by (DEP or NACC number)
the North Andover Conservation Commission.
&
3. I hereby affirm and acknowledge that I have received said Order of Conditions and
have read the same and understand each
(DEP File#) and every condition which has been set forth
in said Order of Conditions.
I &
4. I hereby affirm and acknowledge that on this day of 19_
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 Order of Conditions are presently in compliance.
(DEP File#)
&
5. I hereby affirm and acknowledge that this document will be relied upon by the
North Andover Conservation Commission as well as any potential buyers of
said property which is subject to said Order of Conditions
(DEP File#)
Signed under the pains and penalties of perjury this day of 19
(Signature-authorized agent of applicant or owner)
7A7_1 G4O 1171 R.o.,+... -4 114-1.n(-t('l 11 MAnr 11/11ZOAV)