HomeMy WebLinkAboutNOI Signature Page
wpaform3.doc • rev. 6/18/2020 Page 9 of 9
4
Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Wetlands WPA Form 3 – Notice of Intent
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40
Provided by MassDEP:
MassDEP File Number
Document Transaction Number
City/Town
F. Signatures and Submittal Requirements
I hereby certify under the penalties of perjury that the foregoing Notice of Intent and accompanying
plans, documents, and supporting data are true and complete to the best of my knowledge. I understand
that the Conservation Commission will place notification of this Notice in a local newspaper at the
expense of the applicant in accordance with the wetlands regulations, 310 CMR 10.05(5)(a).
I further certify under penalties of perjury that all abutters were notified of this application, pursuant to
the requirements of M.G.L. c. 131, § 40. Notice must be made by Certificate of Mailing or in writing by
hand delivery or certified mail (return receipt requested) to all abutters within 100 feet of the property line
of the project location.
1. Signature of Applicant
Sept. 15, 2023
2. Date
3. Signature of Property Owner (if different)
4. Date
5. Signature of Representative (if any)
Sept. 15, 2023
6. Date
For Conservation Commission:
Two copies of the completed Notice of Intent (Form 3), including supporting plans and documents,
two copies of the NOI Wetland Fee Transmittal Form, and the city/town fee payment, to the
Conservation Commission by certified mail or hand delivery.
For MassDEP:
One copy of the completed Notice of Intent (Form 3), including supporting plans and documents, one
copy of the NOI Wetland Fee Transmittal Form, and a copy of the state fee payment to the
MassDEP Regional Office (see Instructions) by certified mail or hand delivery.
Other:
If the applicant has checked the “yes” box in any part of Section C, Item 3, above, refer to that
section and the Instructions for additional submittal requirements.
The original and copies must be sent simultaneously. Failure by the applicant to send copies in a
timely manner may result in dismissal of the Notice of Intent.