CH15 15 .9 - Request for Certificate of Preliminary Plat Approval

Name(s) of Subdivider(s)       ____________________          _____________________


Address(es)                            _____________________         _____________________


Phone(s)                                 _____________________         _____________________


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




















I (we) do hereby request primary 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 the subdivision.


Name of the Subdivision ______________________________generally described as  follows:


Civil Township _____Section_____Quarter Section_____Township_____Range______


Area in acres___________________________________; Number of lots____________


Miles of new streets to be dedicated to the public (in hundredths):


Full width__________________________


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


Notary Public

Residing in _________________County

My Commission Expires: _________


Staff Use: Date of  Public Hearing before Commission  ___________________________

Fee For Additional Lots of  $_______received from subdivider.  Date ____________

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