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Northampton Conservation Commission and Girl Scouts ANR Haydenville Road Leeds Section Owner Information Permit Application Please note: If this form sits idle for more than 30 minutes, you will have to start over. A red dot to the left of a field name indicates the field is required. A green dot indicates the requirement has been fulfilled. Please enter the property's owner information Section Applicant Information Please enter the applicant's information Section General Information To complete the following section you will need the assessor's map-block-lot (##-##-###) and zoning district for all parcels involved in the project. If this project contains multiple parcels, please separate section-block-lot with semi-colons ";" Click the following link to look up a map-block-lot number or zoning district: Click here to look up a map-block-lot or zoning information • Property Owner Name: Western Massachusetts Girl Scout Council • Property Owner Address:  Haydenville Road • Property Owner City: Leeds • Property Owner State Massachusetts  • Property Owner Zip Code: 01053 • Applicant Information:  Same as property owner? • Is the applicant a City of Northampton city government department? Yes  • Permit Applicant Name: City of Northampton--Conservation Commission • Permit Applicant Address:  210 Main Street, Room 11 • Permit Applicant City: Northampton • Permit Applicant State: Massachusetts  • Permit Applicant Zip Code: 01060 • Permit Applicant Phone Number: Format: ###-###-#### 413-587-1265 • Permit Applicant Email: WFeiden@NorthamptonMA.gov LincDoc™ Page 1 of 4 https://northampton.lincware.com/lincdoc/?northampton.Northampton_ApplicationForPermit 2/2/2012 Section Permit Type What PERMITS or AMENDMENTS are you applying for (check all that apply) (NO application is complete until the fee is paid, AND, if required for your permit, checks for legal ads made out to "Daily Hampshire Gazette" and recording fees made out to "Commonwealth of Massachusetts." • How many lots will this project contain: 2 • Street Number of project: 0 • Street Name of project: HAYDENVILLE RD  • Choose City and Zip Code where proposed work is located: Leeds 01053  • Registry of Deeds or Land Court deed book and page number for work location B.1478, P.381 • Zoning Districts and Overlay Districts for work location: RR • Assessors map # for work location: 06  • Assessors block # for work location: 044  • Assessors lot # for work location: 001  • Please select the permit type:  Planning Bd. Special Permit w/Site Plan -$200  Planning Bd. Special Permit w/Site Plan for flag lots -$1000  Planning Bd. Special Permit w/MAJOR Site Plan NO Special Permit -$1000 plus $0.05/sq. ft  Planning Bd. Site Plan (NO Special Permit) -$200  Administrative Site Plan Review -$100  Planning Bd. Major Site Plan Approval (No Special Permit), including 40R projects -$1000 plus $0.05/sq. ft  Approval Not Required Plans -$250/plan page  Subdivision Preliminary -$600 plus $75 per unit  Subdivision Definitive IF Preliminary approved GREATER of $3000 or $10 linear foot of road  Subdivision Definitive IF NO Preliminary GREATER of $4600 or $14 linear foot of road  Subdivision Definitive Amendment -$500  Zoning Board Special Permit -$200  Zoning Board Finding -$200  Appeal of Building Commissioner-Zoning -$200  Comprehensive Permit (40B) -$1000  Variance -$1000  Demolition (Demolition Delay) -$200  Historic District Determination of Non-Applicability -$0  Historic District (Elm St) Determination of Appropriateness -$200  West Street Architecture -$200  Central Business Architecture -$200  Wetlands Notice of Intent, Abbreviated NOI or ANRAD, IF state LincDoc™ Page 2 of 4 https://northampton.lincware.com/lincdoc/?northampton.Northampton_ApplicationForPermit 2/2/2012 Section Additional Information Section Fee Amount Section Special Permit and/or Site Plan Describe in detail how you meet ALL SEVEN requirements: 1. Will protect adjoining premises from seriously detrimental uses. 2. Will minimize and mitigate traffic impacts. 3. Promote a harmonious relationship of structures and open space. 4. Protect the general welfare. 5. Avoid overloading and mitigate impacts on City resources. 6. Promote city planning objectives (see Sustainable Northampton, Open Space Plan, and Transportation Plan). 7. Meet all zoning requirements. Section ANR Plans, Preliminary and Definitive Subdivisions Approval Not Required plans MUST include: 1. ANR signature block with note "Planning Board Endorsement is not a determination that the lots shown are buildable lots". 2. A table showing a list of all Assessors Parcel ID being altered. 3. Each parcel showing its current Northampton Assessors Parcel ID. 4. Control points when required by the Northampton Subdivision Regulations. wetlands (WPA Form 3, 3, 4, or 4A) -$100 plus city share of state fee  Wetlands Notice of Intent IF ONLY local wetlands (WPA Form 3) -$100 plus $100 per lot/building/unit  Wetlands Request for Determination OR Resource Delineation (WPA form 1 or 4a) -$125  Wetlands Amendment or extension -$50  Wetlands Certificate of Compliance request -$0 • How many plan pages are there: 1 • Existing use of your structure or property:  Passive recreation and conservation under Girl Scout ownership • Describe planned use, your proposed project and your request in DETAIL (include relevant sections of regulations) AND whether you have discussed this with your neighbors:  Passive recreation and conservation under Conservation Commission ownership, possibly with Smith Vocational Agricultural School maintaining timber cutting in the forest • Fee amount: 0.00 • Describe:  NOT APPLICABLE LincDoc™ Page 3 of 4 https://northampton.lincware.com/lincdoc/?northampton.Northampton_ApplicationForPermit 2/2/2012 Section Upload All Projects Attach text and supporting information describing project as a multi-page TIF or PDF. If file size is too large, digital file must be included with submittal. Section Upload Plan Sheets Upload all plan sheets showing existing and proposed work as a multi-page TIF or PDF named 'plansheets.' If the file size is too large digital file must be included with submittal. Section Upload Approval Not Required Upload an electronic copy of the ANR Plan in AutoCAD 2000 format with all parcels closing, to an accuracy of 1:25,000. You must ALSO attach the same plan as a MULTIPAGE TIF or PDF. If the file size is too large, a digital file, must be included with submittal. Section Signature By typing my name in the signature box, I certify that all the information above is accurate to the best of my knowledge, I am the property owner or have permission from the property owner to apply for this permit. I also grant permission to the City of Northampton to inspect the proposed work. submit cancel • • Describe:  All included • Upload: upload (max is 8.0 MB) clear • Upload: upload (max is 8.0 MB) clear • Autocad 2000 format upload: upload (max is 8.0 MB) clear • Tiff or PDF format upload: upload (max is 8.0 MB) clear • Signature: Wayne Feiden • Date Signed: LincDoc™ Page 4 of 4 https://northampton.lincware.com/lincdoc/?northampton.Northampton_ApplicationForPermit 2/2/2012