ANRLNDORSLIVILI N T O.[+ Ekz'IIROVAL NO'. RE QUIRE D (ANIt) ;PLAN -- _ _
File With the Office O h ltllnning alld ,Developmeint
City of Nadhamptoll, Ilatlssuchusea.y
c�i3 -ice- r�� ��i�,�Y�, �3d� �✓��/ �.��,t��� �vc/�r� i� �o �3�,�'3
1. Deed recorded in Hampshire County Registry of Deeds or Land Court: Boot PagC ,
2.
3. Assessor's Map: _16fC� Lot(s): �' Additional properly dcsC1'Ipt1011:
zL.— Number- ofncwly_crcatcd- lots:- - - - - -� - - -— -- - -
5. Check list of riling requirements (check the sul)l)licd 1Lcros. Applications MUST have these netts.)
❑ Original, reproducible (nlylar) Plan, with endorsed Scal ofa M assachusetts Registered
Professional Land Surveyor.
❑ Six (6) prints of the Plan.
❑ Original and Six (6) copies of the fully completed and endorsed ANIZ Application form.
❑ $150 per sheet fee plus $50 for each newly created lot (payable to "City of Northampton ").
❑,_.. If any portion of a plan falls within-500.fcct of a publ.islled..control.point (see _ ..... -- ...._._..:
NorthamptonPlanniiig.org): four cm LimcLcr- a ccuracy points on ca(;h sheet lied into the
Massachusetts State Plane Coordinate System CHAD 1983 datum) llSlng Said lRiblishcd control
points or Lhe global l)osltloning system and - noting 111C coordin of the tie -in points, the datum,
and tllc source and IOCilL1011 Of 1110nU111CIlts used for d ata.
❑ An electronic version of the plan in model space in DWG, DXF, or Shape l6rmat including:
o All properly lines, buildings and geographic FCatures shown on'thc plans.
o Closure of all property boundaries of one parL in 20,000
❑ Plans 'show all buildings owned by subject landowncr(s) within 100' of any newly created
property lines.
❑ 1 ?tans ,include a statement that the Planning Board's cnclorsciucnl is not a determination that the
lots shown are buildable lots.
We believe and understand that:
(1) The attached plan is not a division as defined in the Subdivision Control L aw and we submit
it for endorsement that Planning Board approval under this Law is not required; and
(2) we have provided all the information required in the chccklisL above; and
(3) The plans submILLcd arc now in the public domain and play be copied freely in any form.
Applicant (print or type): Signature:
Acid ress: -:!9 L� s�i �s~� G�� Phonc: - -4126P
Owncr (print or type): S WIG Signature:
Address: - P11011c:
Surveyor (print or typc) ;&C,�71i 2l_� 7-442? 0,�1 Signature:
Phone:
illlol•v 2 1 -clay fo r- p I is the apl) lican t's r(- to pick u the oi g i nal dr' a wili if and
rccordit at the Regi ofDeeds or Land Cour within the time limits astablished by the Ref, /111
copies a nd fa•rrns remain with the City, ilpplicanls may file orne copy of this 11NIi form with the City Cleric
to pr•olect their appeal rights.
Dille SUbl11ittCd: _ - - Date Decision Filed: - -
Ciiy Clerk (signature):_ _ _ _
(ANK Application. Form A: last revised 112 312 0 02)
- City Clerk(signaturc):