APPENDIX A: CERTIFICATION FORMS AND CHECK LISTS

FORM A
CERTIFICATION OF THE APPROVAL OF WATER AND SEWERAGE SYSTEMS

(to appear on preliminary and final plats)

I hereby certify that the                water supply and                   
sewage disposal utility systems installed, or proposed for installation in the subdivision entitled:               
fully meets the requirements of the Kentucky State Health Department, and hereby approved as shown.

      19      
Date

   County Health Officer or other Approving Agent

(Blanks to be filled with the words "private" or "public".)

FORM B

(to appear on the preliminary and final plats)

CERTIFICATE OF AVAILABILITY OF WATER SERVICES

I hereby certify that,                     * shall supply the
                      Subdivision with water services and that the water distribution systems of said subdivision meets the requirements of this agency and all other requirements for the proper distribution of water.

      ,19         
Engineer of the Appropriate Agency

* (Name of company or agency distributing water)

FORM C

(to appear on the preliminary and final plats)

CERTIFICATE OF THE AVAILABILITY OF SEWAGE DISPOSAL SERVICES

I hereby certify that               * shall supply the                 subdivision with sewage disposal services and
the sewage disposal system of said subdivision meets the requirements of this agency and all other requirements for the proper disposal of sewage.

      ,19      
Engineer of the Appropriate Agency

*(Name of company or agency supplying sewage disposal services.)

FORM D

(to appear on final plat)

CERTIFICATE OF OWNERSHIP AND DEDICATION

I (we) hereby certify that I am (we are) the owner(s) of the property shown and described hereon and that I (we) hereby adopt this plan of subdivision with my (our) free consent, establish the minimum building restriction lines, and dedicate all streets, alleys, walks, parks and other open spaces to public or private use as shown in accordance with the Murray Subdivision Regulations, unless otherwise noted.

      ,19      

Owner               

Owner               

FORM E

(to appear on final plat)

CERTIFICATE OF ACCURACY

I hereby certify that the plan shown and described hereon is a true and correct survey to' the accuracy required by the Murray, Kentucky Planning Commission and that the monuments have been placed as shown hereon to the specifications of the County Engineer or City Engineer.

         ,19         

   Registered Engineer or Surveyor

(Stamp)

FORM F

(to appear on the final plat)

(Use Form F-1 when improvements have been made before final approval)

(Use Form F-2 when security is to be posted)

F-1
CERTIFICATION OF THE APPROVAL OF STREETS AND UTILITIES

I hereby certify that all streets, utilities, and other improvements have been installed in an acceptable manner and according to the city specifications
in              subdivision.

         ,19      

Date

                  City Engineer or Approving Agent

F-2
CERTIFICATION OF THE APPROVAL OF STREETS AND UTILITIES

I hereby certify that the proposed streets, construction plans for all streets, utilities and other improvements in            
subdivision do meet the city speculations.

Furthermore, a            * in the amount of $         has been posted with the Murray Legislative Body to assure the completion of all required improvements in case of default.

      ,19         
Date

                        City Engineer or Approving Agent

*(This blank to be filled in with the words, "cash". "certified check". or "security bond".)

FORM G

(to appear on final plat)

CERTIFICATE OF APPROVAL FOR RECORDING

I hereby certify that the subdivision plat shown hereon has been found to comply with the Subdivision Regulations for Murray, Kentucky, with the exception of such variances, if any, as are noted in the minutes of the Planning Commission, and that it has been approved for recording in the Office of the County Clerk.

      ,19         

   Chairman or Secretary of the Planning Commission

PRELIMINARY PLAT - CHECK LIST

(to be filed with minutes)

Name of subdivision                              

Location                                 

Owner                  Tel.       

Address                                 

Surveyor or Engineer                   Tel.      

Address                                 

Date Submitted                   Fees $         

Meeting Date                  

CHECK LIST

   Fees Paid

   Approval of County Health Officer received

   Approval of Water Distribution System received

   Approval of Sewerage System received

   Three (3) copies received

   Approved paper size (18"x24" or 24"x36")

   Map (1" = 200' or greater)

SHOWN ON PLAT

   Name and location of subdivision

   Vicinity Map

   Name and address of owners

   Name and seal of engineer or surveyor

   Acreage of land to be subdivided

   Date

   Graphic scale

   North point

   Certificates on plat

   Adjacent property owners

   Contours at 5' or lesser intervals

   Boundary lines

   Proposed and existing easements on and adjacent to tract and their dimensions

   Present and proposed utilities on and adjacent to tract and proposed connections

   Lot line and lot numbers Public sites

   Setback lines

   Protective covenants

   Portion of larger tract and data shown

Approval given                Refused               

Grounds for refusal, if not shown above or conditions or modifications required         

Variances granted (if any)                              

Subject to approval of Board of Adjustments                        

Approval received?                                 

Date of action of Planning Commission                        

   Chairman, Murray Planning Commission

FINAL PLAT - CHECK LIST
(to be filed with minutes)

Name of subdivision   
Location   
Owners    Tel.      Address      
Surveyor or Engineer    Tel.       Address      
Date Submitted ,    Fee $         

Date preliminary plat approved                  
   Minor plat   
Meeting Date   

CHECK LIST

      Construction completed, security posted
      Fees paid
      Certificate of Ownership and Dedication
      Certificate of Accuracy
      Approval of County Health Department
      Approval of Water Company
      Approval of Sewerage System
      Approval of City Engineer
      The original plat and six (6) copies submitted
      Approved paper size (18"x24" or 24"x36")
      Maps (1" = 100' or larger)
      Name of subdivision
      Name and address of owner
      Name of the engineer or surveyor and seal
      Acreage of tract
      Date
      Graphic scale
      True north point
      Certificates on plat
      Boundary lines and dimensions
      All street rights-of-way and dimensions
      All easements and dimensions
      Lot lines and dimensions
      Setback lines
      Bearing, radii of angles
      Name of street
      Lot numbers and street numbers
      Name of adjoining subdivisions and property owner
      Protective covenants
      Location of monuments
      Profile sheets and street plans
      (Contours on minor plats)