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OFFICE OF
PLANNING BOARD
Town Of Belchertown
P.O.
Box 964
Belchertown,
Massachusetts 01007
FORM A
APPLICATION FOR ENDORSEMENT OF PLAN
BELIEVED NOT TO REQUIRE
APPROVAL (ANR)
Date
__________________
Note: File one completed Form A, plus the original Mylar
plan and four copies of the plan with the Planning Board. Additionally, file a completed copy of Form
A (with fee as determined by Planning Office) with the Town Clerk, in accordance
with the requirements of MGL C.41 §81T.
The undersigned, believing that the accompanying
plan of land in the Town of Belchertown does not constitute a subdivision
within the meaning of the Subdivision Control Law, submits this plan for a
determination and endorsement that Planning Board approval under the
Subdivision Control Law is not required.
Each
owner and applicant, including spouses, MUST sign. The application will not be accepted without each signature. If the applicant or owner is a corporation, trust, or other such
entity, proof of signatory authority must be provided.
1. Applicant(s)
_________________________________________________________
Address
________________________________Telephone ________________
2. Name
of Owner(s) _____________________________________________________
(if
other than applicant)
Address
__________________________________Telephone
________________
3. Name of Engineer or Surveyor
__________________________________________
Address
__________________________________Telephone
________________
4. Deed of Property recorded in Hampshire
Registry of Deeds:
Book
____________________________Page ______________________________
5. Evidence of Qualification and Division of
Land:
a. Number of existing
lots
b. Area of
existing lot or lots
c. Frontage of
existing lot or lots
d. Number of
proposed lots
e. Minimum area
of proposed lot or lots
f. Minimum
frontage of proposed lots
g. Minimum width
of proposed lots
h. Required frontage located on
(Name
of Street)
said street or way being:
_____
an accepted way.
_____
a way certified by the Town Clerk as used
and maintained as a public way.
_____ a
way on an endorsed subdivision plan.
_____ a
way in existence when the Subdivision Control
Law became effective, and which
is adequate in the opinion
of the Planning Board.
or, _____ the
lot is not intended as a building lot.
i. said lots being:
_____
a proposed lot
conveyance, or other instrument
which adds to or takes away from,
or changes the sizes
and shape of lots, such that
no lot affected is left
without required frontage.
_____ a
division of a tract of land because two or more
buildings were standing prior to
the date when
Subdivision Control Law went into
effect in Belchertown
and one of said buildings remain
standing on each of said
lots.
Evidence of existence of such buildings as follows:
___________________________________________
(Attach Evidence)
6. Existing
Assessors map and lot numbers for lot identification: (must appear on plan):
Map
#(s)
Existing
Lot #(s)
Proposed
Lot Identification for plan purposes (A, B, C…) (Assessors will assign lot numbers
later)
_____________________________________________
Signature of Applicant
_____________________________________________
Signature of Applicant
_____________________________________________
Signature of Owner (if other than applicant)
_____________________________________________
Signature of Owner (if other than applicant)
Continued on Page 3 --
_______________________________________________________________________________
For Office Use
Planning Board Fee:
Cost $
Signature:
Received by Town Clerk:
Date: Time:
Amount Received: $
Signature:
Picked up mylar from the Planning Board Office:
Print Name:
Signature: Date: