OFFICE OF

PLANNING BOARD

Town Of Belchertown

P.O. Box 964

Belchertown, Massachusetts 01007

FORM C

APPLICATION FOR APPROVAL

OF A DEFINITIVE PLAN

Belchertown Planning Board

, 20

File one completed application form together with prints of plan and other necessary documentation with the Planning Board and one copy with the Town Clerk in accordance with the requirements of Chapter 270, Article IV, Section 270-22 of the Code of the Town of Belchertown (Subdivision Regulations).

Town staff will not fill any part of this out for you. It must be submitted with all the required information. An incomplete application may delay the review of your subdivision plan.

To the Planning Board:

The applicant represented on this application submits the accompanying Definitive Plan of property located in Belchertown for approval as a subdivision under the requirements of the Subdivision Control Law, M.G.L. Ch. 41, Sec. 81L, and Chapter 270, Subdivision of Land, in the Town of Belchertown.

1. Applicant

Address Telephone

2. Owner or owners of land

Address Telephone

3. Engineer

Address Telephone

4. Surveyor

Address Telephone

5. Deed of property recorded in the Hampshire Registry of Deeds,

Book , Page

6. Location and description of property

7. Attach a cost estimate for the construction according to §270-31E(5) (Form G).

8. Attach a list of the names and addresses of the abutters and property owners within 300 feet of this subdivision as received from the assessors' office (Form D).

9. The following are all the mortgages and other liens or encumbrances on the whole or any part of

the above described property:

10. Attach a municipal lien certificate from the Belchertown Town Treasurer-Collector. According to §65-2 of the town code, the Planning Board "may deny…any…permit…on or about real estate whose owner has neglected or refused to pay any local taxes, fees, assessments, betterments or any other municipal charges…"

11. The applicant hereby covenants and agrees with the Town of Belchertown upon approval of the definitive plan:

a. To design and construct the ways, and to design and install the municipal services, according to Chapter 270, Subdivision of Land, in the Town of Belchertown.

b. To design and construct the subdivision according to the rules and instruction of the Belchertown Board of Health, the Belchertown Conservation Commission, and other appropriate departments.

c. To construct the ways and install the municipal services according to the definitive plan and its accompanying material as finally approved and endorsed by the Planning Board.

d. That at the laying out and acceptance of the subdivision's ways, all the municipal services within the ways shall become the property of the Town of Belchertown at no cost to the town, unless otherwise agreed upon in writing.

12. Title of definitive plan

a. Was a preliminary subdivision plan submitted? Yes No

b. If Yes, the preliminary plan this definitive plan evolved from was submitted to the Planning Board on (date).

c. The preliminary plan was: approved ,

approved with modifications , or

disapproved .

d. Date of Planning Board decision on the preliminary plan .

This agreement shall be binding upon the heirs, executors, administrators, successors, and assigns of the undersigned owner or owners of record:

--- on page 3 ---

Owner 1 ______________________________ _____________________________

(print or type name) (signature)

Address _____________________________________________________________________

Owner 2 ______________________________ _____________________________

(print or type name) (signature)

Address _____________________________________________________________________

Owner 3 ______________________________ _____________________________

(print or type name) (signature)

Address _____________________________________________________________________

COMMONWEALTH OF MASSACHUSETTS

Hampshire, ss _____________________ , 20 _____

Then personally appeared ___________________________________ , the owner, and acknowledged the foregoing instrument to be the free act and deed of said party(ies) before me.

_________________________________________

Notary Public

My commission expires ______________________

COMMONWEALTH OF MASSACHUSETTS

Hampshire, ss _____________________ , 20 _____

Then personally appeared ___________________________________ , the applicant, and acknowledged the foregoing instrument to be the free act and deed of said party(ies) before me.

_________________________________________

Notary Public

My commission expires ______________________

Town Clerk:

Date of submission: _____________________________

Amount submitted ______________________________

Signature ______________________________________