OFFICE OF

PLANNING BOARD

Town Of Belchertown

P.O. Box 964

Belchertown, Massachusetts 01007

FORM D

CERTIFIED PARTIES IN INTEREST

FOR DEFINITIVE SUBDIVISION,

SITE PLAN APPROVAL, VARIANCE, SPECIAL PERMIT

and

ZONE CHANGE REQUESTS

Date: , 20

Board of Assessors:

The following is to be completed by Assessors:

The subject property is: Map #/s: ______________________________________________

Lot #/s: ______________________________________________

Please attach a list of abutters within three hundred (300’) feet of the outer perimeter of the subject property:

Please attach a copy of the Assessors Map indicating subject property and near abutters.

I certify that this lists of persons are the abutters of record of the subject property (with 300 feet of the outer perimeter of the subject lot).

_____________________________

Assessor or Verifier

_____________________________

Date of Verification

Town Planning Boards to be notified: Amherst, Granby, Ludlow, New Salem, Palmer, Pelham and Ware;

and all Belchertown town boards.