Lenox Town Hall
6 Walker Street, Lenox, MA 01240
ph: 413-637-5500
Form E

_____________, 20________
To the Planning Board of the Town of Lenox:
I hereby certify that the required improvements for the following described subdivision have been constructed and conform in all respects to the Rules and Regulations of the Planning Board and the recommendations of the Board of Health and the specifications of the Board of Selectmen.
Subdivision Names (or Plan Title)_______________________________
Name of Subdivider__________________________________________
Street Name(s)______________________________________________
Stations ____________________________________ to ________________ _________________
        Civil Engineer                                   Land Surveyor
        _______________________                 _____________________________
        Address                                                   Address
        _________________________         ______________________________
Registration Number & Seal Registration Number & Seal