(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-O, MGL, for approval of a proposed subdivision plan, hereby submits a Definitive Plan and makes application for approval to the North Andover Planning Board:

1. Name of Applicant: __________________________________________

Address: _____________________________________________________

2. Name of Subdivision: _________________________________________

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

_____________________________________________________________

4. Deed Reference: Book. __________, Page ___________ or

Certificate of Title _____________________

5. Name of Surveyor/Engineer: _____________________________________

Address: _______________________________________________________

Easements & Restrictions of Record (Describe &Include Deed References):

_______________________________________________________________

6. Preliminary Plan Submitted? _______; Plan Approved? __________; Date: ____________

Signature of Owner(s): _____________________________________________

Address: ________________________________________________________

________________________________________________________________

Received: Town of North Andover Town Clerk (date stamp): Signature of Town Official receiving this application:

____________________________________________________