DATE: _________________

(Stamp two (2) forms with the Town Clerk. File one (1) form with the Town Clerk and one (1) form with the Planning Board)

To the Planning Board:

The undersigned, being an applicant under Chapter 41, 81-S, MGL, for approval of a proposed subdivision plan, hereby submits a Preliminary Plan and makes application for approval to the North Andover Planning Board:

1. Name of Applicant: ___________________________________________________

Address: ______________________________________________________________

2. Name of Subdivision: __________________________________________________

Location and Description of Property [include Assessor's Map and Lot and Zoning District(s)]: ______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

3. Deed Reference: Book._________, Page ___________ or

Certificate of Title: __________________________________

4. Name of Surveyor: __________________________________

Address: ____________________________________________

____________________________________________________

Signature of Owner(s): _________________________________

Address: ____________________________________________

____________________________________________________

Received: Town of North Andover Town Clerk (date stamp):

____________________________________________________

Signature of Town Official receiving this application:

____________________________________________________