Wpa Form 1 – Fill Out and Use This PDF

Important:	1.	Applicant:
When filling out
forms on the
computer, use
		Name		E-Mail Address
only the tab key
to move your
		Mailing Address
cursor - do not
use the return
key.		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		make the following determination(s). Check any that apply:
	Conservation Commission

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).

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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):

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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.)

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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

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