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2. First Name*
3. Last Name*
5. Date*
   Date
6. Map/Lot*
8. Project Address*
10. Project purpose and need*

    In order to request a waiver, this provides a guidance for required information

12. Attach additional text, plans, photos, or graphics if needed
14. What specific action(s) is the waiver being asked for?*
16. How is the action(s) in the public interest, necessary to prevent a safety hazard or water dependent?*
18. How is the action(s) consistent with the intent and purpose of the bylaw?*
20. Existing and proposed site conditions (ie, impervious, lawn & disturbed areas) (square feet;show on plan)*
22. Existing and proposed distances of land uses from wetland resource areas (show on plan)*
24. Analysis of less environmentally damaging practicable alternative*
26. Proposed short term and long term protection of wetland resource areas*
28. Is the site in a Zone I, II, or III (groundwater) or Zone A, B, or C (surface water) water supply area*
30. Are there critical, unique, or sensitive resource areas in the area (ie, NHESP mapped habitat, vernal pools, unusual wetland types, cold water fisheries, outstanding resource waters, core habitat, conservation land, etc); show on plan*
32. Other factors for consideration
34. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
36. Electronic Signature
38. Project*
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39. Print Only

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