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 ____________