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

_____________, 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)_______________________________
                                                        
Dated______________________________________
                                                        
Name of Subdivider__________________________________________
                                                        
Street Name(s)______________________________________________
                                                        
Stations ____________________________________ to ________________ _________________
                                                        
        Civil Engineer                                   Land Surveyor
                                                        
        _______________________                 _____________________________
                                                        
        Address                                                   Address
                                                        
        _________________________         ______________________________
                                                        
Registration Number & Seal Registration Number & Seal