LARGE PROJECT REVIEW: BOUNDARIES OF THE LONGWOOD INSTITUTIONAL AREA FOR THE PURPOSE OF APPLYING SECTION 80B-2.2(d)

(1)

Name of Project: _________________________________________

(2)

Location: _________________________________________

(3)

Applicant: _________________________________________

(4)

I hereby state, under the penalties of perjury, that the true names and addresses of all Persons who have a Beneficial Interest (including the amount of their Beneficial Interest accurate to within one-tenth of one percent if such interest exceeds one percent) in the above-listed property are listed below in compliance with the provisions of Article 80, Section 80B-8, of the Boston Zoning Code.

NAME AND RESIDENCE OF EACH PERSON WITH SAID BENEFICIAL INTEREST
(continue on separate sheet if necessary):

(5)

The undersigned also acknowledges and states that except as stated below, none of the above-listed individuals is an official elected to public office in the Commonwealth of Massachusetts, nor is an employee of the State Department of Capital Planning and Operations.

(6)

I hereby state, under the penalties of perjury, that the names and addresses of all firms and professional corporations employing attorneys, real estate brokers, architects, engineers, planners, or surveyors, and all other agents who have acted on behalf of any of the foregoing with respect to the application for Zoning Relief on the above-listed property are listed below in compliance with the provisions of Article 80, Section 80B-8, of the Boston Zoning Code.

NAMES AND ADDRESSES OF ALL FIRMS AND PROFESSIONAL CORPORATIONS, AND AGENTS WHO HAVE ACTED ON SAID APPLICATION
(continue on separate sheet if necessary):

SIGNED under the penalties of perjury.

Signature: ____________________________________________________________

Name Printed: ____________________________________________________________

Date: ____________________________________________________________