HomeMy WebLinkAboutApplication - 143 LACY STREET 4/19/2013 2013 AfT 19 A I I
APPENDIX B ® APPLICATION
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PLANNING DEPARTMENT
Community Development Division
Land Disturbance Permit Application
Please type or print clearly.
1.Petitioner: V�6
1.0 Petitioner's Address: 7 -7— 637,�- e 6x
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Telephone number: 5 1 �
—426 4P al/ 61:2 L
2.Owners of the Land: 0 441(. -;:6t111.4Vt1 PWP-14,4 "�C,
Address: 11/3 zel&z ;5= Atht�4 ly-W160c?4— M& 0041—c--
Number of years of ownership:
3.Address of Property Being Affected: -57—
Zoning District:
Assessors Map: -,-1(15 --ol 7p,-o)AOt#: i LL
Registry of Deeds:Book#: c9l V6 Page
4.Description of Project:
5.Total Area to be Disturbed
6. Has there been a previous application (Special Permit or Definitive Subdivision)from the Planning Board on these
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premises? If so,when and for what type of construction?
7. Has there been a previous application (NOI/RDA, Small Project, Certificate of Compliance)from the Conservation
Commission on these premises?_ f so,when and what type?
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8. Petitioner and Landowner signature(s):
Every application for a Land Disturbance Permit shall be made on this form, which is the official form of the
Planning Board. Every application shall be filed with the Town Clerk's office. It shall be the responsibility of
the petitioner to furnish all supporting documentation with this application. The dated copy of this
application received by the Town Clerk or Planning Office does not absolve the applicant from this
responsibility.The petitioner shall be responsible for all expenses for filing and legal notification. Failure to
comply with application requirements, as cited herein and in the Planning Board Rules and Regulations
may result in a dismissal by the Planning Board of this application as incomplete.
Petitioner's Signature: ,
Print or type name here: !' tii�;,� C)
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Owner's Signature: (,
Print or type name here: ti' ( (.�c
9. Please list title of plans and documents you will be attaching to this application.
10.Application Fee to be included with the Application is$300,made payable by check to the Town of North Andover.
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