Provided by MassDEP:
Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands
MassDEP File Number
WPA Form 3 – Notice of Intent
Document Transaction Number
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40
Wayland City/Town
Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key.
A. General Information 1. Project Location (Note: electronic filers will click on button to locate project site): Lake Cochituate
Wayland
a. Street Address
b. City/Town
Latitude and Longitude:
01778 c. Zip Code
42.296933
-71.369441
d. Latitude
e. Longitude
n/a
n/a
f. Assessors Map/Plat Number
g. Parcel /Lot Number
2. Applicant:
Note: Before completing this form consult your local Conservation Commission regarding any municipal bylaw or ordinance.
Michael
Lowery
a. First Name
b. Last Name
Lake Cochituate Watershed Council c. Organization
Post Office Box 183 d. Street Address
Natick
MA
01760
e. City/Town
f. State
g. Zip Code
508-397-8828
508-370-4509
lowery.mike@gmail.com
h. Phone Number
i. Fax Number
j. Email Address
3. Property owner (required if different from applicant):
Check if more than one owner
Tom
Flannery
a. First Name
b. Last Name
MA Department of Conservation & Recreation - Lakes & Ponds Program c. Organization
251 Causeway Street d. Street Address
Boston
MA
02114
e. City/Town
f. State
g. Zip Code
617-626-1250
617-626-1455
Tom.Flannery@state.ma.us
h. Phone Number
i. Fax Number
j. Email address
4. Representative (if any): Michael
Lowery
a. First Name
b. Last Name
Lake Cochituate Watershed Council, Inc. c. Company
Post Office Box 183 d. Street Address
Natick
MA
01760
e. City/Town
f. State
g. Zip Code
508-397-8828
508-370-4509
lowery.mike@gmail.com
h. Phone Number
i. Fax Number
j. Email address
5. Total WPA Fee Paid (from NOI Wetland Fee Transmittal Form): $500.00 waived
$237.50 waived
$262.50 waived
a. Total Fee Paid
b. State Fee Paid
c. City/Town Fee Paid
wpaform3.doc • rev. 11/16/09
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