Name(s) of Subdivider(s)           ____________________ _____________________

 

Address(es)                               _____________________ _____________________

 

Phone(s)                                   _____________________ _____________________

 

Subdivider's Representative (if any) and Registered Land Surveyor (if any):

 

Name(s)                                   _____________________ _____________________

 

Address(es)                               _____________________ _____________________

 

Phone(s)                                   _____________________ _____________________

 

I (we) do hereby apply for sketch Plan review and certificate or approval of the following described subdivision in accordance with the provisions of the Lapel Subdivision Ordinance.  I (we) am (are) the owner (owners) of the real estate included in said subdivision.

 

Name of the Subdivision ______________________________generally described as  follows:

Civil Township _____Section_____Quarter Section_____Township_____Range______

 

                           (LEGAL DESCRIPTION OF SUBDIVISION ATTACHED HERETO)

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The undersigned, having been duly sworn on oath states the above information is true and correct as he is informed and believes.

 

Signature(s) of Subdivider(s) ___________________________________________

 

___________________________________________

State of Indiana           )

 

County of _______         )           SS:

Subscribed and sworn to before me this day of _______________________, 19___.

________________________

Notary Public

Residing in _________________County

My Commission Expires: _________

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Staff Use: Date of Concept Plan Review ___________________________

Fee of $___________received from subdivider.  Date ____________