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WPA1-50Cookewpaform1.doc Page 1 of 4 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands WPA Form 1- Request for Determination of Applicability Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 City/Town A. General Information Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. 1. Applicant: Name E-Mail Address Mailing Address City/Town State Zip Code Phone Number Fax Number (if applicable) 2. Representative (if any): Firm Contact Name E-Mail Address Mailing Address City/Town State Zip Code Phone Number Fax Number (if applicable) B. Determinations 1. I request the Conservation Commission make the following determination(s). Check any that apply: a. whether the area depicted on plan(s) and/or map(s) referenced below is an area subject to jurisdiction of the Wetlands Protection Act. b. whether the boundaries of resource area(s) depicted on plan(s) and/or map(s) referenced below are accurately delineated. c. whether the work depicted on plan(s) referenced below is subject to the Wetlands Protection Act. d. whether the area and/or work depicted on plan(s) referenced below is subject to the jurisdiction of any municipal wetlands ordinance or bylaw of: Name of Municipality e. whether the following scope of alternatives is adequate for work in the Riverfront Area as depicted on referenced plan(s). wpaform1.doc Page 2 of 4 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands WPA Form 1- Request for Determination of Applicability Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 City/Town C. Project Description 1.a. Project Location (use maps and plans to identify the location of the area subject to this request): Street Address City/Town Assessors Map/Plat Number Parcel/Lot Number b.Area Description (use additional paper, if necessary): c.Plan and/or Map Reference(s): Title Date Title Date Title Date 2.a. Work Description (use additional paper and/or provide plan(s) of work, if necessary): wpaform1.doc Page 3 of 4 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands WPA Form 1- Request for Determination of Applicability Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 City/Town C.Project Description (cont.) b.Identify provisions of the Wetlands Protection Act or regulations which may exempt the applicant from having to file a Notice of Intent for all or part of the described work (use additional paper, if necessary). 3.a. If this application is a Request for Determination of Scope of Alternatives for work in the Riverfront Area, indicate the one classification below that best describes the project. Single family house on a lot recorded on or before 8/1/96 Single family house on a lot recorded after 8/1/96 Expansion of an existing structure on a lot recorded after 8/1/96 Project, other than a single family house or public project, where the applicant owned the lot before 8/7/96 New agriculture or aquaculture project Public project where funds were appropriated prior to 8/7/96 Project on a lot shown on an approved, definitive subdivision plan where there is a recorded deed restriction limiting total alteration of the Riverfront Area for the entire subdivision Residential subdivision; institutional, industrial, or commercial project Municipal project District, county, state, or federal government project Project required to evaluate off-site alternatives in more than one municipality in an Environmental Impact Report under MEPA or in an alternatives analysis pursuant to an application for a 404 permit from the U.S. Army Corps of Engineers or 401 Water Quality Certification from the Department of Environmental Protection. b.Provide evidence (e.g., record of date subdivision lot was recorded) supporting the classification above (use additional paper and/or attach appropriate documents, if necessary.) wpaform1.doc Page 4 of 4 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands WPA Form 1- Request for Determination of Applicability Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 City/Town D. Signatures and Submittal Requirements I hereby certify under the penalties of perjury that the foregoing Request for Determination of Applicability and accompanying plans, documents, and supporting data are true and complete to the best of my knowledge. I further certify that the property owner, if different from the applicant, and the appropriate DEP Regional Office were sent a complete copy of this Request (including all appropriate documentation) simultaneously with the submittal of this Request to the Conservation Commission. Failure by the applicant to send copies in a timely manner may result in dismissal of the Request for Determination of Applicability. Name and address of the property owner: Name Mailing Address City/Town State Zip Code Signatures: I also understand that notification of this Request will be placed in a local newspaper at my expense in accordance with Section 10.05(3)(b)(1) of the Wetlands Protection Act regulations. Signature of Applicant Date Signature of Representative (if any) Date Work Description There is a current ‘carport’ structure, in the rear of the yard, that was erected in 1965 and must be replaced since it cannot be repaired. Attached is picture of the current structure, which consists of 12 metal posts and a canopy over an existing parking lot/storage yard. It measures approximately 32’ x 48’ and is located 50’ from the brook at its closest point. The new structure will have the same footprint and setbacks to the Pine Brook. Scope of work: 1) Demolish the old structure and haul debris to Valley Recycling. 2) Bury precast frost posts in the ground. Holes to be dug about 36” square by 48” deep. Plan to use 8 posts, but not more than 12. Once poles are in place, the holes will be backfilled immediately. If any extra backfill left, all material will be hauled offsite or outside the buffer zone. If needed, silt fence can be erected during construction. Installation of posts will take less than one day. 3) A canopy will be placed on top of the poles and attached properly. Installation of canopy will take one day.