HomeMy WebLinkAboutOutside Consultant Agreemant_Signed - - 135 COACHMANS LANE I
Town of North Andover
Planning Department
Community&Economic Development Division
120 Main Street
North Andover, MA 01845
(#593)
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OUTSIDE CONSULTANT ESCROW AGREEMENT
NORTH ANDOVER PLANNING BOARD
Agreement is made this c-rcl, z� between the Town of North Andover and
William Belan er of 135 Coachman's Lane North Andover,MA for
subdivision, site plan review first fl()o living space.
Know ALL men by these present that the Applicant hereby provides the Town of North Andover with a check in the
sum of t1oot oft to be deposited in an interest-bearing account as designated by the Town Treasurer to be
expended by the North Andover Planning Board to insure payment to an outside consultant(s)for engineering reviews for
the above referenced project.
This Agreement shall remain in full force and effect until this Applicant, or his/her/its executors, devises,
administrators, heirs, successors, and assigns has fully and satisfactorily performed all obligation specified herein. Upon
completion by the Applicant of all obligations specified herein,the remaining funds(unless less than ten dollars), including 1
accumulated interest, in said account shall be returned to the Applicant.
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Planning Board Chairman or Agent Applicant
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Date Date
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120 Main Street North Andover,Massachusetts 01845
Phone 978.688.9535 Fax 978.688.9542 Web ,WWAw ttlL Lg1q,,,,,gov
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COMMONWEALTH OF MASSACHUSETTS
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Then personally appeared as the Applicant or his/its authorized agent and acknowledged the
foregoing instrument to be his or her free act and deed the free act and deed of the Applicant,before me.
Notary PublicIo
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COMMONWEALTH OF MASSACHUSETTS '�V� r,F
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Then personally appeared as the Planning Board Chair or his/her
authorized agent and acknowledged the foregoing instrument to be hisllher free act and deed and the free act and deed of
the Applicant, before me.
Notary Public
My Commissions Expires
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120 Main Street North Andover, Massachusetts 0184 5
Phone 978.688.9535 Fax 978.688.9542 Web wVM0otjtjnv ° gay
TOWN OF NORTH ANDOVER
DIVISION OF FINANCE
120 Main Street
North Andover,MA 01845
Tel: (978)688-9520 Fax: (978) 688.9522
Escrow Account Application:
Master Account: Town of North Andover-Plannin ACC#00 02520 8 j
Sub-Account: _._ ,._._. _ ......_. ._. .,.,....._.. .. ...
Address for Form 1099 - ..-- .--••, ,, -. �, -- ---- •••-
Initial Deposit: 2,000.00 .---...—,-(check payable to Town of North Andover)
Certification of Taxpayer Identification Number
Under penalties of perjury, I/we certify(1)that the number shown on this form is my/our correct taxpayer identification
number and (2)that I/we are not subject to backup withholding either because I/we have not been notified that I/we are
subject to backup withholding as a result of a failure to report all interest or dividends,or the Internal Revenue Service has
not notified me/us that I/we are no longer subject to backup withholding.
NOTE: Strike out text following (2)above is signer has been notified signer is subject to backup withholding due to payee
under-reporting and has not received notice from the Internal Revenue Service that backup withholding has terminated.
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Signature _,,, `�
`'P'` Date
Print Name: William Bela,n e► Title .
for Town use only: TO: CENTURY BANK
Please transfer the amount of$ from master acct#�„ ..............
To
Date J
Acct Id: 1
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120 Main Street North Andover,Massachusetts 01845
Phone 978.688,9535 Fax 978.688.9542 Web . rrrttiL�ve�rl, ll
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