APPENDIX A
REQUIRED STATEMENTS AND SIGNATURES TO BE AFFIXED ON SUBDIVISION PLAT
   Situated in the County of Perry, State of Ohio, and being of Section           , Township                   , Range                   , containing               acres and being the same tract as conveyed to                                                 , and described in deed recorded in Deed Book                     , Page               , Recorder’s Office, Perry County, Ohio.
The undersigned                                             hereby certify that the attached plat correctly represents their “                                                     ” a subdivision 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 Perry County, 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 public utility lines or services, 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                           ,         .
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. 82-16.  Passed 4-19-82.)