Fillable MESA Checklist (Commonwealth of Massachusetts)

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MESA Checklist (Commonwealth of Massachusetts)

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The MESA Checklist (Commonwealth of Massachusetts) form is 2 pages long and contains:

  • 2 signatures
  • 4 check-boxes
  • 49 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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MESA Project Review Checklist
Massachusetts Endangered Species Act M.G.L. c.131A and Regulations (321 CMR 10.00)
1) Project Location:
Street Address/Location City/Town Zip Code
Assessors Map/Plat Number Parcel /Lot Number
Property recorded at the Registry of Deeds for:
County Certificate # (if registered land)
Book Page Number
2) Applicant:
First Name Last Name Company
Mailing Address
City/Town State Zip Code
Phone Number Fax Number Email address
3) Property owner (if different from applicant):
First Name Last Name Company
Mailing Address
City/Town State Zip Code
Phone Number Fax Number Email address
4) Representative (if any):
Company
Contact Person First Name Contact Person Last Name
Mailing Address
City/Town State Zip Code
Phone Number Fax Number Email address
Additional Information
1. Will this project require a filing with the Conservation Commission and/or DEP? No Yes
2. Has this project previously been issued a NHESP Tracking Number (either by previous NOI Submittal
or MESA Information Request Form)? No  Yes, if Yes -Tracking No.______________
Project Description (attach separate sheet, as needed)
Please note, certain projects or activities are exempt from review, see 321 CMR 10.14. The MESA does not allow
project segmentation. Your filing must reflect all anticipated work associated with the proposed project (CMR 321
10.16).
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
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Include the Following Information:
ALL Applicants must submit:
• USGS map (1:24,000 or 1:25,000) with property boundary clearly outlined
• Project plans for entire site (including wetland Resource Areas, showing existing and proposed
conditions, existing and proposed tree/vegetation clearing line, and clearly demarcated limits of
work)
• Assessor’s map or right-of-way plan of site
• Statement/proof that applicant is the Record Owner or that applicant is a person authorized in
writing by the record owner to submit this filing
• Photographs representative of the site
Projects altering 10 or more acres, must also submit:
• A vegetation cover type map of the site
• Project plans showing Priority Habitat boundaries
The NHESP may request additional information, such as, but not limited to, species and habitat surveys,
wetland reports, soil map and reports, and stormwater management reports (321 CMR 10.16). The
NHESP will notify the applicant within 30 days if the materials submitted do not satisfy requirements for
a filing and request submission of any missing materials (321 CMR 10.18(1)).
Filing Fee, Payable to Comm. of MA - NHESP (see website for fee information)
a. Total MESA Fee Paid__________ b. Acreage of Disturbance__________ c. Total Site Acreage_______
Required Signatures
I hereby certify under the penalties of perjury that the foregoing MESA filing and accompanying plans,
documents, and supporting data are true and complete to the best of my knowledge.
Signature of Property Owner/Record Owner of Property Date
Signature of Applicant (if different from Owner) Date
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MESA Checklist (Commonwealth of Massachusetts)

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Completed 26 July 2020

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