CH15 15 .8 - Application for Concept Plan Review and Certificate


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______




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: _________


Staff Use: Date of Concept Plan Review ___________________________

Fee of $___________received from subdivider.  Date ____________

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