Application for Special Permit
1
Form A, Application for non-subdivision plan (Approval Not Required), Belchertown Planning Board
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.
1. Applicant ______
Address ______Telephone ______
2.Name of Owner ______
(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 (if NOT the owner)
______
Signature of Owner
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: