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Home My WebLink AboutMiscellaneous - 200 VEST WAY 4/30/2018 (3)CONSERVATION DEPARTMENT Community Development Division NEGATIVE DETERMINATION OF APPLICABILITY SPECIAL CONDITIONS 200 Vest Way, ,North Andover At the January 8, 2014 public hearing, the North Andover Conservation Commission (NACC) voted to issue a Negative Determination of Applicability for the installation of clean fill in an area defined on the herein referenced plans within the buffer zone to Isolated Vegetated Wetland (IVB. The fill area is more than 60 -feet from IVW at its closest point. All stockpiled brush shall be removed from the 25 -foot No - Disturb Zone (NDZ) and the resource area as required by the previously approved Small Project Permit (NACC #101) and Determination of Applicability (DOA) issued in 2012. Owner: John Charles Lewis, III and Dale Lewis 200 Vest Way North Andover, NIA01845 Representative: the Architects David A. Kinsella, AIA, President 7 Bridge Street, Suite 9 Billerica, MA 01821 Record Documents: Request for Determination of Applicability Form 1 and supporting materials, submitted: December 27, 2013 Plan Titled: Plan of Land in North Andover, Massachusetts Prepared by Merrimack Engineering Services 66 Park Street Andover, MA 01810 Stamped by: Stephen k. Stapinski Date: October 3, 2012'with Edits by the Representative Plan Titled: Basement Plan w/Proposed Fill Prepared by the Architects/Builder Stamped by: David A. Kinsella, RA 1600 Osgood Street, Suite 2035, North Andover, Massachusetts 01845 Phone 978.688.9530 Fax 978.688.9542 Web: http://www.townofnorthandover.com/Pages/NAndoverMA_Conservation/index Date: 12/27/13 i Wetland Delineation by Norse Environmental 9/26/2012 SPECIAL CONDITIONS: Prior to the start of construction the applicant shall ensure that the site contractor has reviewed the small project permit and is aware of the wetland resource area and the limits of the proposed work. 2. Prior to the start of .filling activities, the contractor will install erosion controls (hay bales and trenched siltation fence or other erosion control as approved by the Conservation Department). Erosion controls will be installed up -gradient of the 50 -foot No -Build Zone. 3. Once erosion controls are installed, the contractor will contact the Conservation Department to schedule a preconstruction meeting to inspect the installed erosion controls. 4. Machinery access will be from the right side of the house (facing it from the road). 5. Prior to the start of construction, the applicant shall install two (2) wetland markers (available at the Conservation Department —1 round 1 square) at the existing tree line (as required by NACC #101 and the previously issued DOA). 6. The brush pile located in the wetland area shall be removed and disposed of offsite. No brush shall be dumped or stored within 25 feet of the edge of the wetland (see NACC#101 and previously issued DOA). 7. Accepted engineering and construction standards and procedures shall be followed in the completion of the project. 8. Excess fill material shall be properly disposed of offsite. 9. Once construction is completed, all disturbed areas will be loarned and hydro seeded. 10. Upon completion of the approved project and site stabilization (hydro seeded areas are ready to be mowed), please contact the Conservation Department for a final inspection. Once approved, erosion controls can be removed. 1600 Osgood Street, Suite 2035, North Andover, Massachusetts 01845 Phone 978.688.9530 Fax 978.688.9542 Web: http://www.townofnorthandover.com/Pages/NAndoverMA_Conservafon/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 i 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 your cursor - do not use the Dale Lewis return key. MA 01845 Name Name 200 Vest Way Mailing Address Mailing Address North Andover Property Owner (if different from applicant): ' City/Town State ' Zip Code City/Town State 1. Title and Date (or Revised Date if applicable) of Final Plans and Other Documents: Plan of Land October Title Date Basement Plan with Proposed Fill 12/27/13 Title Date Title 2. Date Request Filed: i i 12/27/13 I I I B. Determination Date Zip Code W49 Pursuant to the authority of M.G.L. c. 13.1, § 40, the Conservation Commission considered your Request for Determination of Applicability, with its supporting documentation, and made the following Determination. ' Project Description (if applicable): Installation of clean fill around exisitng covered porch within the Buffer Zone to Bordering Vegetated Wetland. Project Location: 200 Vest Wav Street Address ' Map 104D Assessors Map/Plat Number North Andover City/Town Parcel 105 Parcel/Lot Number wpaform2.doc -Determination of Applicability -rev. 08113 Pagel 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 Determinations) 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 Iplan(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. 08/13 1Page 2 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.) ❑ 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 plan(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. i 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 ❑ 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. 08/13 Page 3 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.) ❑ 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 ini 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 i C. Authorization This Determination is issued to the applicant and delivered as follows: ❑ by hand delivery on [� by certified mail, return receipt requested on L 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 i http://www. mass. gov/eea/agencies/massdep/about/contacts/find-the-massdep-req io nal-office-for-vo u r- city-or-town.html) and the property owner (if different from the applicant). Date wpaform2.doc - Determination of Applicability - rev. 08/13 1 Page 4 of 5 LI,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 U. 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 hftp://www.mass.gov/eea/agencies/massdep/about/contacts/find-th massdep-regional-office-for-your-city-or-town html) 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. 08/13 � Page 5 of 5 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. rab n=mm Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands Request for Departmental Action Fee Transmittal Form Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 A. Request Information 1. Person or party making request (if appropriate, name the citizen group's representative): Name Mailing Address City/Town Phone Number Project Location Mailing Address State Fax Number (if applicable) Zip Code City/Town 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 Phone Number 3. DEP File Number: B. Instructions State Fax Number (if applicable) Z -1N %,VuC 1. When the Departmental action request is for (check one): ❑ Superseding Order of Conditions ($120 for individual single family homes with associated structures; $245 for all other projects) ❑ Superseding Determination of Applicability ($120) ❑ Superseding Order of Resource Area Delineation ($120) 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. 08113 Page 1 of 2 Massachusetts Department of Environmental Protection Bureau 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/eea/agencies/massdep/about/contacts/find-the-massdep-regional-office-for- your-city-or-town. html). 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. 08/13 Page 2 of 2 CONSERVATION DEPARTMENT Community Development Division NEGATIVE DETERMINATION OF APPLICABILITY SPECIAL CONDITIONS 200 Vest Way, North Andover At the November 14, 2012 public hearing, the North Andover Conservation Commission (NACC) voted to issue a Negative Determination of Applicability for the construction of an 18' x 21' deck expansion within the buffer zone to Isolated Vegetated Wedand'(IVW). The deck expansion is 69 -feet from IVW at its closest point. All stockpiled brush shall be removed from the 25 -foot No -Disturb Zone (NDZ) and the resource area as required by the previously approved Small Project Permit (NACC #101). i Owner: John Charles Lewis, III and Dale Lewis 200 Vest Way North Andover, MA01845 Applicant: Robert Buthmann Box 193 Seabrook, NH 03874 Record Documents: Request for Determination of Applicability Form 1 and supporting materials, submitted: October 31, 2012 Plan Titled: Plan of Land in North Andover, Massachusetts Prepared by Merrimack Engineering Services 66 Park Street Andover, MA 01810 Stamped by: Stephen E. Stapinski Date: October 3, 2012 Wetland Delineation by Norse Environmental 9/26/2012 SPECIAL CONDITIONS: i 1. Prior to the start of construction the applicant shall ensure that the site contractor has reviewed the small project permit and is aware of the wetland resource area and the limits of the proposed work. 2. All work will be done using hand held equipment. 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_Conservation/index i 3. Prior to the start of construction, the applicant shall install two (2) wetland markers (available at the Conservation Department —1 round 1 square) at the existing tree line (as required by NACC #101). 4. The brush pile located in the wetland area shall be removed and disposed of offsite. No brush shall be dumped or stored within 25 feet of the edge of the wetland (see NACC#101). 5. Accepted engineering and construction standards and procedures shall be followed in the completion of the project. i 6. Excess construction material shall be properly disposed of offsite. i 7. Upon completion of the approved project and site stabilization, please contact the Conservation Department for a final inspection. 1600 Osgood Street, Building 20, Suite 2-36, North Andovet, Massachusetts 01845 Phone 978.688.9530 , Fax 978.688.9542 Web: http://www.townofnorthandover.com/Pages/NAndoverMA_Conservation/index Massachusetts Department of Environmental Protection L, Bureau of Resource Protection - Wetlands I WPA Form 2 — Determination of Applicability Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 { A. General Information Important: From: When filling out City/Town Parcel 105 forms on the North Andover computer, use Conservation Commission only the tab key to move To: Applicant your cursor - do not use the Robert Buthmann return key. Name P. O. Box 193 Property Owner (if different from applicant): 1 Dale Lewis Name 200 Vest Way k Mailing Address Mailing Address Seabrook NH 03874 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: Plan of Land October 3, 2012 Title Date Title Title 2. Date Request Filed: 10/31/12 Date Date 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): Expansion of an existing deck within the Buffer Zone to Isolated Vegetated Wetland. I Project Location: 200 Vest Way North Andover Street Address Map 104D City/Town Parcel 105 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 Bureau 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. an(s) and thin an area ect to ❑ protect onwork der the Act and willnremovnced e, fill, dredge, or alter that hahrea Therefore, sad work p 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: Ordinance or Bylaw Citation Name Page 2 of 5 wpaform2.doc • Determination of Applicability • rev. 10/6/04 Massachusetts Department of Environmental Protection LlBureau 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 plan(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 originalparcel 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. Page 3 of 5 wpaform2.doc • Determination of Applicability • rev. 10/6/04 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.) ❑ 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 hftp://www.mass.gov/dep/about/region.findvour.ht and the property owner (if different from the applicant). Date wpaform2.doc • Determination of Applicability • rev. 10/6/04 Page 4 of 5 LI,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 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/abouttregion.findyour.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 1 Page 5 of 5 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands Request for Departmental Action Fee Transmittal Form Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 )LII A. Request Information Person or party making request (if appropriate, name the citizen group's representative): Important: 1 When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Name Mailing Address City/Town State Phone Number Fax Number (if applicable) Project Location Mailing Address Zip Code City/Town ' 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 Phone Number 3. DEP File Number: State Fax Number (if applicable) Zip Code B. Instructions 1. 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 � Page 1 of 2 wpaform2.doc • Request for Departmental Action Fee Transmittal Form • rev. 1016104 Massachusetts Department of Environmental Protection Bureau 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 orband delivery to the appropriate DEP Regional Office (see http://www. mass.qov/dep/about/region/fiindyour. htm). i 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