1105.11   SAMPLE FORMS.
   The sample forms for application, review and approval of preliminary plats, final plat and lot splits are samples of the ones available at the Municipal Building for official use.
(a)   Preliminary Plat Forms.
(Ord. 141-83)
1.   Name of Applicant ____________________
   Address _______________________
   Phone _________________________
2.   Name of Owner of Record ______________
               Address ________________________
3.   Name of Surveyor or Engineer ___________
               Address ________________________
               Phone __________________________
4.   Name of Subdivision ____________________
5.   Locational Description: Section __________ Town __________
                     Range ______________
(In addition, please attach copy of legal description.)
6.   Proposed Use __________________________
7.   Present Zoning District ___________________
8.   Number of Lots ________ Acreage of Parcel _____
9.   Do you propose deed restrictions? Yes ______ No _______
(If yes, please attach a copy.)
10.   In which elementary school district is this parcel located?
(i.e., South, Central, West) _________________
11.   Attach 12 copies of Preliminary Plat.
The undersigned agrees that the submittal date for this plat shall be as defined in Section 1105.03(b)(5), the date on which the Planning Commission first considers the plat at a regular meeting.
Date              Signature of Applicant or Authorized Agent
Date received ____________________
Date of meeting of Planning Commission ____________________ (Official submission date)
Filing Fee:    Amount __________
               Paid by __________
               Check No. __________
               Date __________
Action by Planning Commission _____________
   Date _______________
If plat was rejected, reason(s) for rejection: _______________ ________________________________________________ ________________________________________________
Date __________       _______________
Subdivision ____________________
The following items (do, do not) conform with the requirements of Section 1105.04(b) of the Subdivision Regulations.
   Does   Does Not   Item
   1. __________   __________   Vicinity Map
   2. __________   __________   Subdivision Name
   3. __________   __________   Tract Designation
   4. __________   __________   Names and address of owner, subdivider, surveyor.
   5. __________   __________   Names of adjoining subdivisions and owners of adjacent parcels of unplatted land.
   6. __________   __________   Boundary lines and approximate acreage.
   7. __________   __________   Location and width of existing streets within or adjacent to the tract; features such as rights-of-way, public open spaces, buildings, large trees, water-courses, section and corporation lines, floodway boundaries.
   8. __________   __________   Existing utility lines, culverts, etc. with pipe sizes; proposed sanitary sewer and water lines with proposed connections to existing system; provisions for drainage of storm water.
   9. __________   __________   Existing contours - 2 foot intervals
   10. __________   __________   Layout of proposed streets and lots with dimensions.
   11. __________   __________   Existing zoning, including zoning boundary lines, if any; proposed use and setback lines.
   12. __________   __________   Proposed dedication of public land or reservations for common use of property owners.
   13. __________   __________   North point, scale and date.
   14. __________   __________   Copy of proposed deed restrictions, if any.

Date ___________________________   Title    _____________________________
(b)   Final Plat Forms.
(Ord. 141-83)
City of Fairfield, Ohio
Application for Final Plat Approval
1.   Name of Subdivision ____________________
2.   Name of Applicant ____________________
Address _______________ Phone _______________
3.   Name of Local Agent, if any ____________________
      Address ____________________
4.   Owner of Record ____________________
      Address ____________________
5.   Engineer ____________________
      Address _______________ Phone _______________
6.   Surveyor ____________________
      Address _______________ Phone _______________
7.   Have the necessary construction drawings and construction cost estimates been furnished the City Engineer? _______________
8.   Do you propose deed restrictions? __________ Yes __________ NO (If yes, please attach a final copy.)
9.   Total Acreage ____________________
10.   Zoning Classification of Property ____________________________
                  (i.e., A-1, R-O, R-1, etc.)
11.   Number of Lots ____________________
      Date of Preliminary Plat Approval _______________
12.   Have any changes been made since this Plat was last before the Planning Commission? ____________________
Attach an affidavit of ownership indicating the dates the respective holdings of land were acquired, together with the book and page of each conveyance into the present owner as recorded in records of the Butler County Recorder. This affidavit shall indicate the legal ownership of the property, and the date the contract of sale was executed.
The undersigned agrees that the submittal date for this plat shall be defined as in Section 1105.03(b)(5), the date on which the Planning Commission first considers the plat at a regular meeting.
_______________    __________________________________
Date                    Signature of Applicant or Authorized Agent
   Filing Fee _______________
   Paid by _______________
   Check No. _______________
   Date _______________
Date Received _______________
Date of Meeting of Planning Commission ____________________
   (Official Submission Date)
Action by Planning Commission ___________________________
Date of Action __________________________________
If Plat was rejected, reason(s) for rejection ___________________
_______________      ____________________
Date                 Chairman
(Ord. 141-83.)
Final Plat Checklist
Date _______________
Subdivision ____________________
   The following items (do, do not) conform with the requirements of Section 1105.05(b)
   of the Subdivision Regulations.
   Does   Does Not   Item
1.   __________   __________   Submitted within 12 months of preliminary approval.
2.   __________   __________   Conforms to Preliminary Plat and incorporates suggested changes.
3.   __________   __________   Vicinity sketch.
4.   __________   __________   Boundaries of subdivision.
5.   __________   __________   Location and width of existing public streets.
6.   __________   __________   Bearings and distances of permanent monuments.
7.   __________   __________   Location and material of all permanent monuments.
8.   __________   __________   Layout, including street and alley lines, length of arc radii, points of curvature and tangent bearings, public and private easements, lot lines.
9.   __________   __________   Lots in numerical order.
10.   __________   __________   Municipal, township, county or section lines located within or adjacent to tract.
11.   __________   __________   Dimensions and description of any property dedicated for public use or reserved for common use of property owners.
12.   __________   __________   Easements are provided for watercourses, channels, streams or creeks traversing subdivision and retention/detention facilities and include any flood hazard area. Notes on plat are in conformance with Chapter 1105.
13.   __________   __________   Building setback lines.
14.   __________   __________   Private restrictions, if any.
15.   __________   __________   Name of subdivision.
16.   __________   __________   Name and location of adjoining subdivisions and owners of unsubdivided adjoining property.
17.   __________   __________   Names and addresses of owners, surveyors, engineer and subdivider.
18.   __________   __________   North point, scale and date.
19.   __________   __________   Certification by surveyor, and standard statements regarding easements, lots, streets, etc., and signature blocks.
20.   __________   __________   Statement concerning sewer service charge.
21.   __________   __________   Certificate of title.
22.   __________   __________   Plat of land of dedicators.
23.   __________   __________   Signature of any mortgagor holding mortgage on property.

Date _____________________     ___________________________________
(c)  Lot Split Forms.
(Lot Split)
Fairfield Planning Commission
Fairfield, Ohio
Date _______________
The undersigned applies for Minor Subdivision approval under Section 1105.06 of these Regulations, and certifies all material submitted with this application is true and correct.
In accordance with the provisions of Section 1105.06(a) of Subdivision Regulations of the City of Fairfield, Ohio, this application shall be approved or disapproved within seven working days.
Old Lot No.(s) __________  New Lot No.(s) __________
Address of Property (if applicable) _______________
Located ____________________ (Identify location of property as being off _____ street, or fronting _____ street, etc.)
   Signature _____________________
   Address ____________________
   Phone ____________________
Minor Subdivision approval may be granted only under the following conditions:
1.   The proposed subdivision is along an existing public road and involves no openings, widening or extension of any street.
2.   No more than five lots are involved after the original parcel has been completely subdivided.
3.   The subdivision is not contrary to applicable platting, subdividing or zoning regulations.
4.   The property has been surveyed and a sketch and legal description is submitted.
Note: Three copies of the sketch or plat of survey should be provided with the application.
Action _________________________________________________
Comments ______________________________________________
Filing Fee Amount __________   Approved by City Planning                   Commission Fairfield, Ohio
Paid by _________________      No Plat required
Check No. ______________      _________________________
(Ord. 141-83. Passed 9-26-83.)