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HomeMy WebLinkAbout0422 TURTLEBACK ROAD �,�,,,.� .. ,--..�. .�._.. ...�._ �.._-ter..., .`.�..... -...�. _ _ Application number BUILD►NG -REF o� `�Q......................:....................... T Fee.............................................................................. • • EP 3 0 2020 Building Inspectors Initials.. .. ................................ TOWN OF BA . - 4I�I RNSTABLE Date Issued..... ...........................................I............... Map/Parcel............0.6.z .� .�07................... TOWN OF BARNSTABLE ' EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: 4aa;t TUr---(f, NUMBER , STREET _ . VILLAGE ` Owner's Name: Phone Number SZO- 776 - 5` -?6 - Email Address: Cell Phone Number o-m-e-, T l Project cost $ Check one Residential —Z Commercial 'OWNER'S AUTHORIZATION _ As owner of the above property I hereby authorize to make application for a building permit in accordance with 780 CMR Owner Signature: Date: TYPE OF WORK Siding Windows(no header change)# 2 f - Insulation/Weatherization Doors(no header change)# 3 Commercial Doors require an inspector's review 0 Roof(not applying more than I layer of shingles) Construction Debris will be going to S Fix CIO I '- - - - CONTRACTOR'S INFORMATION - - - - Contractor's name _�a{�, 7 Home Improvement Contractors Registration (if applicable)# 1&S 8,9 6 (attach copy) t Construction Supervisor's License# (attach copy) Email of Contractor Af„a'c06l 7gg va koo , r ovh Phone number -7 2 y- 3F7-6 0S-a ALL PROPERTIES THAT IIAVE YtRUCTURES O ER 75 YEARS OLD OR/F THE SU8/ECT PROPERTY IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. APPLICATION NUMBER............................................................ *For Tents 00,1y* Date Tent(s)will be erected Removed on number of tents total Does the tent have sides? Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X a:I T ��.�X, `"'" " `, X Additional tent dimensions can be attached on a separate piece of paper. Purpose of Event Check one: this event is a: for profit non-profit.event = r- Check one: Food served Yes No Flame Spread Sheet of each tent must'be attached. Prbvide a 'site plan with the location (s)of each tent If food is being served at your event please obtain a Health Department approval between the hours of 8.00am-9.30 am or 3:30 pm-4.30pm, Commercial events may require Fire Department approval - *WOOD/COAL/PELLET STOVES Manufacturer# Model /I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION - Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction-inspection procedures,specific inspections and documentation required by 780 CMR and*the Town of Barnstable. Signature Date AP LICANT'S SIGNATURE Signature Date 9— y0 All permit applications are subject to a building official's"approval prior to issuance. X 0 fi i • ✓ire [�om�rzoiziiwof�c����iGksa euJ�//J , office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual Realsttiati4� Ex i o 1658118--, 05/14/2022 PATRICK JACOBS-, �"I ?^ D/B/A P.JACOBS=CUSTOM CARPENTRY AND 7; REMODELING ' kv\�� , PATRICK JACOB,S , —� ,,, ,r..alCG• �� . 28 W HITTER DR:'a w���; DENNIS,MA 02G38` ~` 'Undersecretary 1; . Nf. Commonwealth of Massachusetts ®1 Division of Professional Licensure „ Board of Building Regulations and Standards ConstrAi6tQ% rvisor A® CS-081040 -ZY o - _ �P ires:04/04/2022 r a PATRICK H 4AC095 i 28 WHITTIER'DRNE DENNIS MA 0. Commissioner r The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): ?&L n r L (010 f Address: Q, o, B 0)( 3q H City/State/Zip: rmAk* . ILA A ua -2 Phone#: -7-7q- _7S 3 -& 6 C r:�_ Are you an employer?Check the appropriate bog: Type of project(required): 1. I am a employer with 4. I am a general contractor and I -time). * have hired the sub-contractors 6. New construction I am a sole p pnetor or panne - listed on the attached sheet. Remodehn ship and have no employees These sub-contractors have g. Demolition working for me in any capacity. employees and have workers' 9. Building addition orkers' ce comp.insurance. required.] 5. We are a corporation and its 10. Electrical repairs or additions 3. I am a homeowner doing all work officers have exercised their 11. Plumbing repairs or additions myself. o workers'co right of exemption per MGL y t c. 152,§1(4),and we have no 12. Roof repairs insurance required,] 13. Other employees. [No workers' comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify er e p ' and penalties of perjury that the information provided above is true and correct Signature: �- Date: Phone#- — gr — Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): , 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions i Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,4 corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the. receiver or trustee of an individual,partnership,association or other legal entity,-employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or.local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence'of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)'or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,adapplicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town maybe provided to the applicant as pioof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner-or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. ' The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents - Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1 877-MASSAFE� Revised 4-24-07 Fax#617-727-7749 www.mas.s.gov/dia I From: wstubler@aol.com, To: wstubler@aol.com, Date: Wed,Sep 2, 2020 11:16 am r P.Jacobs is authorized to do work at 422 Turtleback Rd. Marstons Mills Ma 02648. William Stubler �fv `-�� Assessor's map and lot number .`..�e. ..'. .............. SEPTIC SYSTEM D�l MUST B . INSTALLED IN CO�'PLIAN �j WITH ARTICLE II S7�4� Sewage Permit number ....\J.. I.........................................SANITARY CODE + AND TOWN REGULATIONS. ---— °`T"Er° TOWN OF BARNSTABLE i BJ$B4TOHL$ i o g BUILDING INSPECTOR ar a• APPLICATIONFOR PERMIT TO ... .......................................................................................................... TYPE OF CONSTRUCTION 5.1 �°!l ........al. 4 1.10....................................................:..:.................... ef...................19.;7 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to/the following information: Location ... /Z. G. .✓.� ..............X0........�1lY ...........&. .//. ................................... ProposedUse ............................................................................................................................ Zoning District ..���........................................................Fire District ......... .1 1.?.(/4.A. ... �j; n- Name of Owner ....V-�G5...��WAIV........Address / ./... .7/l'�lrlly f.....�./. ........0�fT Nameof Builder ....................................................................Address .................................................................................... l� ... ................ .... Name of Architect ../../.?/L�� .. ........ . . Ctfj.../� S.Address .......... .. .vf:��� � Number of Rooms �� ..........Jr.................................................Foundation ..�©.�r.....'.... .� .. ll, .3 6 �`!�/f. .......... Exterior .......(/G.✓`�C�...... G � .................................Roofing .iJ. ........ Fc .......... ....J1 � Floors .........��G �f......�1 ............................Interior ..... ........L.i' c,4............................... Heating .........X1 .../....1... 4,A ..:..............................Plumbing ............. .............................................................. Fireplace ......f/ /eft <1 .,�ir l.�=........................Approximate Cost ..... r� `"1 .......................... ............. p .. �......... Definitive Plan Approved by Planning Board -----------_______-----------19_______. Area /../.. ��. /) ... ... Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH Boa, 86 Id 1) a s I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding th above construction. -7 /G Y Name � 9 ...... . � -�...;.... Glassman, Elliot 16263 Permit for one story J No ................. ...................................... single family dwelling lk ............................................................................... q Locat ion 0731 Turtleback Road ................................................................ Marston Mills ................................................................................ Elliot Glassman Owner .................................................................. Type of Construction ........;...................frame.............. ................................................................................ Plot ............................ Lot ................................ Permit Granted ..........June..4.................19 73 ........ ... Date of Inspection . ............ ..... ..... i lei� Date Completed ... ........ ...9.3.....ig PERMIT REFUSED ................................................................ 19 ......................4........................................................ .................................................................................. ................................................................................. ............................................................................... Approved ................................................. 19 ..................................................I............................... . ......................................................... ..................... Massachusetts Department of Environmental Protection Bureau of Resource Protection - Waterways Regulation Program X227713 Chapter 91 Waterways License Application -310 CMR 9.00 Transmittal No. Water-Dependent, Nonwater-Dependent,Amendment G. Municipal Zoning Certificate William T. Stubler, Jr. Name of Applicant 422 Turtleback Road Mystic Lake Marstons Mills Project street address Waterway City/Town Description of use or change in use: Maintain beach house and deck accessory to applicant's single family residence. To be completed by municipal clerk or appropriate municipal official: "I hereby certify that the project described above and more fully detailed in the applicant's waterways license application and plans is riot in violation of local zoning ordinances and bylaws." 2 � o Printed Name of unicipal Official Date ignat a of Municipal Offici Title C ty/Town I CH91App.doc•Rev.6/06 Page 6 of 13 CERTIFY THAT THIS PLAN HAS BEEN PREPARED IN CONFORMITY WITH THE RULES AND REGULATIONS OF THE REGISTERS OF DEEDS OF THE COM-M-ONWEA TH OF MASSACHUSETTS. � JOC�, - hti�tt RALPH �rr, 07 Profess' yor Date: L LAW MARSTON'• . MI'LLS AM 062 PAR 06.1 MCGUIRE, JAMES P.D. & DONNA J: 12 SAWMILL ROAD m�Q� MYSTIC MARSTON MILLS, MA. 02648 LAKE z LOCUS a r ( o�� MIOQLE POND 0 AM 062 •PAR 007 'F STUBLER, WILLIAM T. JR. TR. LOC;US M-AP WILLIAM T. STUBLER, JR. 2007 - 422 TURTLEBACK ROAD MA'RSTONS MILLS, MA. 02648 64 -(N OF A44, � 70 68 62 o ROEERT A. N N 68 DRAKE CIVIL a r ® ?g� No.41642 O � `` ° 7fi o 74 72 'O9p�C�S T EPA Q a WOODED �+ o � Al 52 p 8 54 48 W r� . 2• t�`� S0.48 0 EJCISTING TIMBER 0 RR TIES AND g BRICK:STAIRS 4y 0 Z EXISTING o Q DWELLING w ; m ---I EXISTING"TIMBER Q F— RETAINING W 'L J x c ST ES pg BEACH HOUSE p r ��0 W WOODED ELEVATED 7 x DECK W 42.5' EL. 47.2' i4.2 0 42.6'x IMDODED 22s'f eM TOP CB s`pp 42.1'� S80 53'05"E ELEV. 6.8.70' .. 78 - DATUM• GIS Q 7 qWp . T 73.2 S AM 06.2 PAR 002 7 TgyFS 42.6' . x 7 WILLIAMS, WENDY F. cB. FND. 8200 B:EECHWOOD LANE 0 20 40 70 BETHESDA, MD. 20817 68/ ads I _ 66 58 . _- 6 SCALE: n1"=40' sag 5�2 ae°s PLANS ACCOMPANYING PETITION OF STUBLER, WILLIAM T. JR. TR. ELEVATION DATUM: GIS± WILLIAM T. STUBLER, JR. 2007 TO MAINTAIN A BEACH HOUSE AND DECK ON: MYSTIC LAKE MARSTONS MILLS (BARNSTABLE), MA. DATE: MARCH 03, 2009 SHEET 1 OF 3 A.M. WILSON ASSOC., INC. JOB NO. 2,1>621.0 i q CERTIFY THAT THIS PLAN HAS BEEN PREPARED IN CONFORMITY WITH THE RULES AND REGULATIONS OF THE REGISTERS OF DEEDS OF THE COMMON OF MASSACHUSETTS. OF RA?PH �r� HARLOW �Q F .•�os7 Profes `rveyor Date: EXISTING TIMBER RR TIES'AN:D `� ��P�jN OF 44 4 ss9 BRICK STAIRS W off' ROBERTA. G Z DRAKE ) Q L o rn CIVIL l No.4164 9 BR•I';CK `WALK. � m ,� x . . , RCN. 1 42. ' s `� �Z��ti•T EXISTING TIMBER _ RETAINING WALL x CLJ o � 42.6' STONES Q� BEACH HOUSE c � -7 ELEVATED N x DECK 42.5' EL. 47.2' 74.2 Z rpN ES x f— Z 0 42.6'Lu cC W Q STONES ��. x 70 = O 42.6' U Q L S TO NES / n x \v J 42.6' CB FND. x 68 42.8' 66 56 64 62 58 5 5 0 10 20 4 60 52 48 6 x 43.1' SCALE: r 1"=20' PLANS ACCOMPANYING PETITION OF STUBLER, WI`LLIA.M T. JR. TR. WILLIAM T. STUBLER, JR. 2007 ELEVATION DATUM: GIST TO MAfNTAIN A BEACH HOUSE AND DECK ON: MYSTIC LAKE MARSTONS MILLS (BARNSTABLE), MA. DATE: MARCH 03, 2009 SHEET 2 OF 3 A.M. WILSON ASSOC., INC. JOB NO. 2.1621.0 f r CERTIFY THAT TH=IS PLAN HAS BEEN PREPARED IN CONFORMITY WITH THE RULES AND REGULATIONS OF THE REGISTERS OF DEEDS OF THE COMMON TH OF MASSACHUSETTS. �. RALPH Prof � " .Y- ! urveyor Date: TOP VIEW WEST FACE RR TIE RET. WALL OF p ROBERTA. NZ DRAKE u? o CIVILmi 9 No.41ti42 o� TEP DECK CU w lf 3; ui / / . w N 7.7' BEACH v uw HOUSE w o RRI TIE PET. WALL / / . 14.2' BEACH HOUSE AND DECK BEACH PROFILE: HOUSE 0 5 DECK 7.7' SCALE: 1"=5' ELEVATION DATUM: G.I.S.± NORTH FACE DATE: MARCH 3, 2009 SHEET 3 OF 3 A.M. WILSON ASSOC., INC. JOB NO. 2.1621.0 A Massachusetts Department of Environmental Protection Bureau of Resource Protection - Waterways Regulation Program X227713 Chapter 91 Waterways License Application -310 CMR 9.00 Transmittal No. Water-Dependent, Nonwater-Dependent,Amendment Important:When filling out forms A. Application Information (Check one) on the computer, use only the tab NOTE: For Chapter 91 Simplified License application form and information see the Self Licensing key to move your Package for BRP WW06. cursor-do not use the return Name (Complete Application Sections) Check One Fee Application# key. w WATER-DEPENDENT- General (A-H) ® Residential with <4 units $175.00 BRP WW01a ICI ❑ Other $270.00 BRP WW01 b For assistance ❑ Extended Term $2730.00 BRP WW01c incompleting this .-.._.._.._.._.._.._.._..-..-..-..-..-.._.._..-..-..-..-.._.._..-..-.._.._..-..-.._.._..-..-..-..-..-..-..-..-..-..-..-..-..-..-.._..-..-.._.._..-..-.._.._.._ application,please Amendment(A-H) ❑ Residential with <4 units $85.00 BRP WW03a see the "Instructions". ❑ Other $105.00 BRP WW03b NONWATER-DEPEN DENT- Full (A-H) ❑ Residential with <4 units $545.00 BRP WW15a ❑ Other $1635.00 BRP WW15b ❑ Extended Term $2730.00 BRP WW15c Partial (A-H) ❑ Residential with <4 units $545.00 BRP WW14a ❑ Other $1635.00 BRP WW14b ❑ Extended Term $2730.00 BRP WW14c Municipal Harbor Plan (A-H) ❑ Residential with <4 units $545.00 BRP WW16a ❑ Other $1635.00 BRP WW16b ❑ Extended Term $2730.00 BRP WW16c ._.._..-..-..-..-..-..--.-.-......--._.._..--.-.--..-........-.--.._.._..-..-..-........-.._.._..-..-..-..----.._.._..-..----.._..-..-.._.._..-..-.._..----..- Joint MEPA/EIR(A-H) ❑ Residential with <4 units $545.00 BRP WW17a ❑ Other $1635.00 BRP WW17b ❑ Extended Term $2730.00 BRP WW17c Amendment(A-H) ❑ Residential with <4 units $435.00 BRP WW03c ❑ Other $815.00 BRP WW03d ❑ Extended Term $1090.00 BRP WW03e CH91App.doc•Rev.6/06 Page 1 of 13 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Waterways Regulation Program X227713 Chapter 91 Waterways License Application -310 CMR 9.00 Transmittal No. Water-Dependent, Nonwater-Dependent,Amendment B. Applicant Information Proposed Project/Use Information 1. Applicant: William VT48tu61er, J Name E-mail Address ,422 hT,urtleback_Rd Mailing Address Note:Please refer M 02 8 to the"Instructions" IVlarstons Mills City/Town State Zip Code M M Telephone Number Fax Number 2. Authorized Agent(if any): A.1 M._WiIson Associates, Inc.; Name E-mail Address 20 1Rascally I Rabbit Rd.,_Unit 3, Mailing Address Marstons Mills M p2648 Cityrrown State Zip Code 5084209792 5084 9902 77$ Telephone Number Fax Number C. Proposed Project/Use Information 1. Property Information (all information must be provided): l� Owner Name(if different from applicant) 062/ 007 41°40'31" 70025'14" Tax Assessor's Map and Parcel Numbers Latitude ,422 Turtleback Rd.,_Marstons Mills MA 02648 Street Address and Cityrrown State Zip Code 2. Registered Land X Yes ❑ No 3. Name of the water body where the project site is located: Mystic Lake 4. Description of the water body in which the project site is located (check all that apply): Type Nature Designation ❑ Nontidal river/stream X Natural ❑ Area of Critical Environmental Concern ❑ Flowed tidelands ❑ Enlarged/dammed ❑ Designated Port Area ❑ Filled tidelands ❑ Uncertain ❑ Ocean Sanctuary X Great Pond ❑ Uncertain ❑ Uncertain CH91App.doc•Rev.6/06 Page 2 of 13 Massachusetts Department of Environmental Protection Bureau of Resource Protection -Waterways Regulation Program X227713 Chapter 91 Waterways License Application -310 CMR 9.00 Transmittal No. Water-Dependent, Nonwater-Dependent,Amendment C. Proposed Project/Use Information (cont.) Select use(s)from Project Type Table 5. Proposed Use/Activity description on pg.2of the "Instructions" Maintain beach house and deck. 6. What is the estimated,total cost of proposed work (including materials & labor)? 7. List the name&complete mailing address of each abutter(attach additional sheets, if necessary). An abutter is defined as the owner of land that shares a common boundary with the project site, as well as the owner of land that lies within 50' across a waterbody from the project. James P. D. & Donna 12 Sawmill Road, M_ars_tons Mills MA_0.2.6_4.8 McGuire Address Wendy F. Williams 8200 Beachwood Lane, Bethesda MD 20817 Name Address Name Address D. Project Plans 1. I have attached plans for my project in accordance with the instructions contained in (check one): x Appendix A(License plan) ❑ Appendix B (Permit plan) 2. Other State and Local Approvals/Certifications ❑ 401 Water Quality Certificate Date of Issuance x Wetlands P-1149 + SE3-4786 File Number ❑ Jurisdictional Determination JD- File Number ❑ MEPA File Number ❑ EOEA Secretary Certificate Date ❑ 21 E Waste Site Cleanup RTN Number CH91App.doc•Rev.6/06 Page 3 of 13 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Waterways Regulation Program X227713 Chapter 91 Waterways License Application -310 CMR 9.00 Transmittal No. Water-Dependent, Nonwater-Dependent,Amendment E. Certification All applicants, property owners and authorized agents must sign this page. All future application correspondence may be signed by the authorized agent alone. "I hereby make application for a permit or license to authorize the activities I have described herein. Upon my signature, I agree to allow the duly authorized representatives of the Massachusetts Department of Environmental Protection and the Massachusetts Coastal Zone Management Program to enter upon the premises of the project site at reasonable times for the purpose of inspection." I hereby certify that the information submitted in this application is true and accurate to the best of my knowledge." Applicant's signature Date A. M. Wilson Associates, Inc. Property Owner's signature(if different than applicant) Date Agent's signature(if applicable) Date CH91App.doc•Rev.6/06 Page 4 of 13 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Waterways Regulation Program X227793 Chapter 91 Waterways License Application -310 CMR 9.00 Transmittal No. Water-Dependent, Nonwater-Dependent,Amendment F. Waterways Dredging Addendum 1. Provide a description of the dredging project ❑ Maintenance Dredging (include last dredge date & permit no.) ❑ Improvement Dredging Purpose of Dredging 2. What is the volume(cubic yards) of material to be dredged? 3. What method will be used to dredge? ❑ Hydraulic ❑ Mechanical ❑ Other 4. Describe disposal method and provide disposal location (include separate disposal site location map) 5. Provide copy of grain size analysis. If grain size is compatible for beach nourishment purposes, the Department recommends that the dredged material be used as beach nourishment for public beaches. Note: In the event beach nourishment is proposed for private property, pursuant to 310 CMR 9.40(4)(a)1, public access easements below the existing high water mark shall be secured by applicant and submitted to the Department. CH91App.doc•Rev.6/06 Page 5 of 13 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Waterways Regulation Program X227713 Chapter 91 Waterways License Application -310 CMR 9.00 Transmittal No. Water-Dependent, Nonwater-Dependent,Amendment G. Municipal Zoning Certificate William T. Stubler, Jr. Name of Applicant 422 Turtleback Road Mystic Lake Marstons Mills Project street address Waterway City/Town Description of use or change in use: Maintain beach house and deck accessory to applicant's single family residence. To be completed by municipal clerk or appropriate municipal official: "I hereby certify that the project described above and more fully detailed in the applicant's waterways license application and plans is not in violation of local zoning ordinances and bylaws." Printed Name of Municipal Official Date Signature of Municipal Official Title City/Town CH91App.doc-Rev.6/06 Page 6 of 13 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Waterways Regulation Program X227713 Chapter 91 Waterways License Application -310 CMR 9.00 Transmittal No. Water-Dependent, Nonwater-Dependent,Amendment H. Municipal Planning Board Notification Notice to William T. Stubler, Jr. Applicant: Name of Applicant Section H should 422 Turtleback Rd. Mystic Lake Marstons Mills be completed and Project street address Waterway City/Town submitted along with the original Description of use or change in use: application material. Maintain beach house and deck accessory to applicant's single family residence. To be completed by municipal clerk or appropriate municipal official: "I hereby certify that the project described above and more fully detailed in the applicant's waterways license application and plans have been submitted by the applicant to the municipal planning board." Printed Name of Municipal Official Date Signature of Municipal Official Title Cityrrown Note: Any comments, including but not limited to written comments, by the general public, applicant, municipality, and/or an interested party submitted after the close of the public comment period pertaining to this Application shall not be considered, and shall not constitute a basis for standing in any further appeal pursuant to 310 CMR 9.13(4) and/or 310 CMR 9.17. CH91App.doc•Rev.6106 Page 7 of 13 C Massachusetts Department of Environmental Protection Bureau of Resource Protection - Waterways Regulation Program X227713 Chapter 91 Waterways License Application -310 CMR 9.00 Transmittal No. Water-Dependent, Nonwater-Dependent,Amendment Appendix A: License Plan Checklist General View ❑ PE or RLS, as deemed appropriate by the Department, stamped and signed, in ink, each sheet within 8 1/2 inch by 11 inch border ❑ Format and dimensions conform to"Sample Plan" (attached) ❑ Minimum letter size is 1/8 of an inch if freehand lettering, 1/10 of an inch if letter guides are used ❑ Sheet number with total number in set on each sheet ❑ Title sheet contains the following in lower left: Plans accompanying Petition of[Applicant's name, structures and/or fill or change in use, waterway and municipality] ❑ North arrow ❑ Scale is suitable to clearly show proposed structures and enough of shoreline, existing structures and roadways to define its exact location ❑ Scale is stated & shown by graphic bar scale on each sheet ❑ Initial plans may be printed on bond; final plans due before License issuance must be on 3mil Mylar. Structures and Fill ❑ All Structures and Fill shown in full BLACK lines, clearly labeling which portions are existing, which are Proposed and indicating Existing Waterways Licenses ❑ Cross Section Views show MHW*and MLW*and structure finish elevations ❑ Dredge or Fill, actual cubic yardage must be stated and typical cross sections shown i ❑ All Structures and Fill shown in full BLACK lines, clearly labeling which portions are existing, which are Proposed and indicating Existing Waterways Licenses ❑ Cross Section Views show MHW*and MLW*and structure finish elevations ❑ Dredge or Fill, actual cubic yardage must be stated and typical cross sections shown ❑ Actual dimensions of structures(s) and or fill and the distance which they extend beyond MHW*or OHW* ❑ Change in Use of any structures on site must be stated * See 310 CMR 9.02, Waterways Regulations definitions of High Water Mark, Historic High Water Mark, Historic Low Water Mark, and Low Water Mark. Note: DEP may, at its discretion, accept appropriately scaled preliminary plans in lieu of the plans described above. In general, DEP will accept preliminary plans only for non-water dependent projects and projects covered by MEPA to address site design components such as visual access, landscaping & site coverage. Anyone wishing to submit preliminary plans must obtain prior approval of the DEP Waterways Program before submitting them with their application. CHS)Mpp.doc•Rev.6/06 Page 8 of 13 i Massachusetts Department of Environmental Protection Bureau of Resource Protection - Waterways Regulation Program x227713 Chapter 91 Waterways License Application -310 CMR 9.00 Transmittal No. + Water-Dependent, Nonwater-Dependent,Amendment Appendix A: License Plan Checklist (cont.) Boundaries ❑ Property lines, full black lines, along with abutters' names and addresses ❑ Mean High Water(MHW)*or Ordinary High Water(OHW)*, full black line ❑ Mean Low Water(MLW)*, black dotted line, (.............) ❑ Historic MHW*or OHW* ❑ Historic MLW*(..._... _..._) ❑ State Harbor Lines, black dot-dash line (—. —. —. —)with indication of Chapter&Act establishing them (Ch. , Acts of) ❑ Reference datum is National Geodetic Vertical Datum (NGVD) or(NAVD). ❑ Floodplain Boundaries according to most recent FEMA maps ❑ Proposed & Existing Easements described in metes & bounds Water-Dependent Structures ❑ Distance from adjacent piers, ramps or floats (minimum distance of 25' from property line, where feasible) ❑ Distance from nearest opposite shoreline ❑ Distance from outside edge of any Navigable Channel ❑ Access stairs at MHW for lateral public passage, or 5 feet of clearance under structure at MHW. Non Water-Dependent Structures ❑ Depict extent of"Water-dependent Use Zone". See Waterways Regulations at 310 CMR 9.51-9.53 for additional standards for non water-dependent use projects. Note: Final Mylar project site plans will be required upon notice from the Department, prior to issuance of the Chapter 91 Waterways License. CHMpp.doc•Rev.6/06 Page 9 of 13 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Waterways Regulation Program X227713 Chapter 91 Waterways License Application -310 CMR 9.00 Transmittal No. Water-Dependent, Nonwater-Dependent,Amendment Appendix A: License Plan Checklist Cont. w Reg istry Stadement no 31/2 inche 5 inche Locus Map 3 First Sheet 0 my a, 0 1 „ �21/4 inche CD Sample Plan 81/2 inches P.E. or RIS Stamp �---3 Y4 inches Plan accompany ing Petition of... D EP Stamp First Sheet Only 3/4 " Border CHMpp.doc•Rev.6/06 Pagel 0 of 13 i Massachusetts Department of Environmental Protection Bureau of Resource Protection - Waterways Regulation Program X227713 Chapter 91 Waterways License Application -310 CMR 9.00 Transmittal No. Water-Dependent, Nonwater-Dependent,Amendment Appendix B: Dredging Permit Plan Checklist For projects applying for dredging permits only, enclose drawings with the General Waterways Application that include the following information: General View ❑ Submit one original of all drawings. Submit the fewest number of sheets necessary to adequately illustrate the project on 8-1/2 inch X 11 inch paper. ❑ A 1-inch margin should be left at the top edge of each drawing for purposes of reproduction and binding. A 1/2 inch margin is required in the three other edges. ❑ A complete title block on each drawing submitted should identify the project and contain: the name of the waterway; name of the applicant; number of the sheet and total number of sheets in the set; and the date the drawing was prepared. ❑ use only dot shading, hatching, and dashed or dotted line to show or indicate particular features of the site on the drawings. ❑ If deemed appropriate by the Department, certification by the Registered Professional Engineer or Land Surveyor is included. Plan View ❑ North Arrow ❑ Locus Map ❑ Standard engineering scale. ❑ Distances from channel lines and structures if appropriate. ❑ Mean high water and mean low water shorelines (see definitions of"High Water Mark"and "Low Water Mark" at 310 CMR 9.02, C. 91 Regulations). ❑ Dimensions of area proposed to be dredged or excavated. ❑ Notation or indication of disposal site. ❑ Volume of proposed dredging or excavation. ❑ Ordinary high water, proposed drawdown level, and natural (historic) high water(for projects lowering waters of Great Ponds). Section Views ❑ Existing bottom and bank profiles. ❑ Vertical and/or horizontal scales. ❑ Proposed and existing depths relative to an indicated datum. P 9 P ❑ Elevation and details of control structure (for projects lowering waters of Great Ponds). CH91App.doc•Rev.6/06 Pagel 1 of 13 • Massachusetts Department of Environmental Protection Bureau of Resource Protection - Waterways Regulation Program X227713 Chapter 91 Waterways License Application -310 CMR 9.00 Transmittal No. Water-Dependent, Nonwater-Dependent,Amendment Appendix C: Application Completeness Checklist Please answer all questions in the General Waterways Application form. If a question does not apply to your project write"not applicable" (n/a) in that block. Please print or type all information provided on the form. Use black ink(blue ink or pencil are not easily reproducible, therefore, neither will be accepted). If additional space is needed, attach extra 8-1/2"x 11" sheets of paper. ❑ Proper Public Purpose: For nonwater-dependent projects, a statement must be included that explains how the project serves a proper public purpose that provides greater benefit than detriment to public rights in tidelands or great ponds and the manner in which the project meets the applicable standards. If the project is a nonwater-dependent project located in the coastal zone, the statement should explain how the project complies with the standard governing consistency of the policies of the Massachusetts Coastal Zone Management Program, according to 310 CMR 9.54. If the project is located in an area covered by a Municipal Harbor Plan, the statement should describe how the project conforms to any applicable provisions of such plan pursuant to 310 CMR 9.34(2). ❑ Plans: Prepared in accordance with the applicable instructions contained in Appendix A-B of this application. For initial filing, meet the requirements of 310 CMR 9.11(2)(b)(3). ❑ Applicant Certification:All applications must be signed by"the landowner if other than the applicant. In lieu of the landowner's signature, the applicant may provide other evidence of legal authority to submit an application for the project site." If the project is entirely on land owned by the Commonwealth (e.g. most areas below the current low water mark in tidelands and below the historic high water mark of Great Ponds), you may simply state this in lieu of the"landowner's signature". ❑ Municipal Zoning Certification: If required, applicants must submit a completed and signed Section E of this application by the municipal clerk or appropriate municipal official or, for the initial filing, an explanation of why the form is not included with the initial application. If the project is a public service project subject to zoning but will not require any municipal approvals, submit a certification to that effect pursuant to 310 CMR 9.34(1). ❑ Municipal Planning Board Notification: Applicants must submit a copy of this application to the municipal planning board for the municipality where the project is located. Submittal of the complete application to DEP must include Section H signed by the municipal clerk, or appropriate municipal official for the town where the work is to be performed, except in the case of a proposed bridge, dam, or similar structure across a river, cove, or inlet, in which case it must be certified by every municipality into which the tidewater of said river, cove, or inlet extends. ❑ Final Order of Conditions: A copy of one of the following three documents is required with the filing of a General Waterways Application: (1)the Final Order of Conditions (with accompanying plan) under the Wetlands Protection Act; (2) a final Determination of Applicability under that Act stating that an Order of Conditions is not required for the project; or(3)the Notice of Intent for the initial filing (if the project does not trigger review under MEPA. ❑ Massachusetts Environmental Protection Act(MEPA): MGL 30, subsections 61-61A and 301 CMR 11.00, submit as appropriate: a copy of the Environmental Notification Form (ENF)and a Certificate of the Secretary of Environmental Affairs thereon, or a copy of the final Environmental Impact Report(EIR) and Certificate of the Secretary stating that it adequately and properly complies with MEPA; and any subsequent Notice of Project change and any determination issued thereon in accordance with MEPA. For the initial filing, only a copy of the ENF and the Certificate of the Secretary thereon must be submitted. Note: If the project is subject to MEPA,the Chapter 91 Public Notice must also be submitted to MEPA for publication in the"Environmental Monitor". MEPA filing deadlines are the 151h and 301h of each month. CHMpp.doc•Rev.6/06 Page 12 of 13 • Massachusetts Department of Environmental Protection Bureau of Resource Protection - Waterways Regulation Program X227713 Chapter 91 Waterways License Application -310 CMR 9.00 Transmittal No. Water-Dependent, Nonwater-Dependent,Amendment Appendix C: Application Completeness Checklist (cont.) ❑ Water Quality Certificate: if applicable, pursuant to 310 CMR 9.33, is included. ❑ Other Approvals: as applicable pursuant to 310 CMR 9.33 or, for the initial filing, a list of such approvals which must be obtained. Projects involving dredging: ❑ The term "dredging" means the removal of materials including, but not limited to, rocks, bottom sediments, debris, sand, refuse, plant or animal matter, in any excavating, clearing, deepening, widening or lengthening, either permanently or temporarily, of any flowed tidelands, rivers, streams, ponds or other waters of the Commonwealth. Dredging includes improvement dredging, maintenance dredging, excavating and backfilling or other dredging and subsequent refilling. Included is a completed and signed copy of Part F of the application. Filing your Completed General Waterways Application: ❑ For all Water-Dependent applications—submit a completed General Waterways Application and all required documentation with a photocopy of both payment check and DEP's Transmittal Form for Permit Application &Payment to the appropriate DEP regional office (please refer to Pg. 10 of the"Instructions" for the addresses of DEP Regional Offices). ❑ For all Non Water-Dependent applications—submit a completed General Waterways Application and all required documentation with a photocopy of both payment check and DEP's Transmittal Form for Permit Application & Payment to DEP's Boston office. Department of Environmental Protection Waterways Regulation Program One Winter Street Boston, MA 02108 ❑ Application Fee Payment for ALL Waterways Applications: Send the appropriate Application fee*(please refer to Page 1 of the"Application"), in the form of a check or money order, along with DEP's Transmittal Form for Permit Application &Payment: Department of Environmental Protection P.O. Box 4062 Boston, MA 02211 * Under extreme circumstances, DEP grants extended time periods for payment of license and permit application fees. If you qualify, check the box entitles"Hardship Request" on the Transmittal Form for Permit Application &Payment. See 310 CMR 4.04(3)(c) to identify procedures for making a hardship request. Send hardship request and supporting documentation to the above address. NOTE: You may be subject to a double application fee if your application for Chapter 91 authorization results from an enforcement action by the Department or another agency of the Commonwealth or its subdivisions, or if your application seeks authorization for an existing unauthorized structure or use. CHMpp.doc•Rev.6/06 Page 13 of 13