APPENDIX 1
REQUIRED STATEMENTS AND SIGNATURES
 
Item 1. REQUIRED STATEMENTS AND SIGNATURES
Situated in the County of Tuscarawas, State of Ohio, and being of Section ___________, Township __________________ , containing ___________ acres and being the same tract as conveyed to ________________________ , and described in deed recorded in Deed Book ___________ , Page __________ , Recorder's Office, Tuscarawas County, Ohio.
The undersigned ___________________________________ hereby certify that the attached plat correctly represents their "__________________________________" a sub- division of lots ____________ to _____________ inclusive, do hereby accept this plat of same and dedicate to public use as such all or parts of the roads, boulevards, cul-de-sacs, parks, planting strips, etc. shown herein and not heretofore dedicated.
The undersigned being all the owners and lien holders of the lands herein platted further agrees that any use or improvements made on this land shall be in conformity with all existing valid zoning, platting, health or other lawful rules and regulations of the City of Dover, Ohio, for the benefit of himself and all other subsequent owners or assigns taking title from under or through the undersigned.
Easements shown on this plat are reserved for the construction, operation, maintenance, repair, replacement or removal of the public utility lines or services, and for the express privilege of removing any and all trees or other obstructions to the free use of said utilities and for providing ingress and egress to the property for said purposes and are to be maintained as such forever. Easements are reserved where indicated on the plat for public utility purposes above and beneath the surface of the ground. 
In witness whereof ___________________________________________ have hereunto set their hands this _____________________ day of ________________ , 19_____.
Witness ______________________   Signed ___________________________
______________________    _______________________________
Surveyed and Platted by ______________________________________________________
               Civil Engineers and Surveyors
We do hereby certify that we have surveyed the premises and prepared the attached plat and that said plat is correct.
All dimensions are shown in feet and decimal parts thereof. Dimensions on curves are chord measurements.
By ________________________________
Registered Surveyor #___________
(Ord. 45-67. Passed 8-7-67.)